Mr. Farmer Revisited
Mr. Farmer is your first patient on your next midnight shift. He is 82 years old living at home with his wife, retired on the farm. He drives, and is still cutting wood though he says he has “slowed down a bit lately”.
- Medications: Hydrochlorothiazide, atorvastatin, ASA, tamsulosin, metoprolol
- On examination: BP: 135/70, HR 90, T 37.6; Sat 96%
- No focal findings on any system. Hematology/chemistry/urine – all within normal limits.
- Watch the video below and answer the questions that follow.
Re-Examine the Evidence
- What else would you like to know?
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What does “he’s slowed down a bit lately” mean?
You need to be precise about what this means. Does it mean “over the past two years” (ie does she really mean she thinks he has some dementia? If that’s the case then delirium would be much more likely. And it would make his account of the history much less reliable.)
Or does it mean “over the past two days.” This would mean an acute change consistent with delirium or an acute illness or injury.
Or does it mean “over the past two days.” This would mean an acute change consistent with delirium or an acute illness or injury.
What does “the past few days” mean?
Two helpful questions:
- “What has changed? This allows you to narrow in on what is new and different.
- “What made you decide to come to the ED now (Wednesday at midnight)” The answer may be “well it wasn’t till this evening that he fell down!” Or “That’s when he couldn’t talk for ten minutes.”
It is essential when exploring Atypical Presentations to establish what is new and when did it happen.
How do you interpret “couldn’t finish the chores today?”
If, for every day of his life, he has been “finishing the chores” then the fact that he suddenly can’t do so suggests a significant change in his function. Acute functional decline is one of the main presenting symptoms of acute illness in the older person. We often label it “failure to cope” when we really mean “failure to make a diagnosis!”
Review of Medication
Here is an opportunity for a “brown bag biopsy.” Go through his meds carefully:
- Has he taken some extra anti-hypertensives (because he remembers that’s what happened “the last time I had a heart problem.”)
- Has he taken some extra of alpha-blocker (because “I thought it was my prostate.”)
- Is there a new OTC (Gravol? “Because I was feeling nauseous”)”
- Was a new medication (donepezil, nitrofurantoin) added last week that they’ve both forgotten to mention?
Abdo surgery? What do the scars suggest?
It’s important to use poly-modal history-gathering in the “poor historian.” If he still has his gall bladder then that’s the most likely source of abdo problems, pointing you towards ultrasound instead of CT.
“He just doesn’t look right, doc.”
The “general impression” part of the physical exam may be the most telling. And let’s be honest – who do you think knows this person better? You, the emerg doc, who has been with him for 10 minutes; or his daily companion of 60 years? It is foolhardy to ignore or discount family observations.
Are the vitals really normal?
Yes they look “normal.”
- But isn’t 135/70 a bit unusual for an elderly hypertensive? Is this actually hypotension for him?
- And his normal HR of 90? But if he’s beta and alpha-blocked what are the chances it would get higher?
- Afebrile and not hypoxic? Could he have pneumonia? Only a chest x-ray will tell.
Assessment
- So what could this man have?
Discussion: Mr. Farmer Revisited
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would need to do CT head/blood work. wife and patient poor historian of time line.
Ok
ok
ok
interesting to see the impact a vague historian can have in complicating the differential diagnosis.
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Blood work
Totally
Ok, makes sense
Ok
ok
true
d
interesting.
OK
HYEAH
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Highlights importance of avoiding diagnostic closure
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It is NOT necessary to comment in every Discussion box to obtain credit.
true
very true. excellent teachable points
great activities
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great
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T
more in depth history
More history
finally
ok thanks
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Vague presentation
ok
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good point
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nice
Good information
great
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great
good
good
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ok
great
interesting
elderlycan have multiple contributing causes
interesting eye opener
ok
good info
need more info
interesting patient
precisely
k
okay
thanks very much very educational
great review
good
very good feedback
very important information
UTI as a diagnosis of exclusion in the elderly with vague complaints -this would substantially change the practice of many ERPs if this were common knowledge
j
agree that UTIs are overdiagnosed and treated in elderly
ok
Hhh
Useful vignettes
Very useful review
great
interesting
great point
good point, great learning
great ddx
cool
ok
ok
a lot to consider
these are the potential diagnosis for this case.
great example
Not sure what else to do for complaints so vague other than admit for observation
good list
all excellent points
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great great points
makes sense
good points!
ok
very interesting the fact that UTI is diagnosed by exclusion. is common in elderly having asymptomatic bacteriuria
Good stuff for review.
yes I agree
Lots of info
very good
great escenario
very interesting. Emphasizes the tough job we have in diagnosing the elderly
Thanks
So if I’m inferring correctly, an elderly patient coming with “weakness” or “functional decline” with no focal findings, normal initial BW and a relatively non-specific collateral history should have (sequentially or in one go) a full Sepsis BW (including trops) + CXR + Head CT + Abdo CT w/ contrast + Med review + DRE + Derm exam + Depression Screen + serial ECGs + (even maybe) an LP before we can conclude that nothing is going on. Just wondering how other people would use this info while still moving patients efficiently through the department. I can see myself ordered a Sepsis panel + single trop + ECG + CT Head + CXR + screening mood/skin and then if that’s normal and patients vitals are still normal admit for observation or discharge with close follow up.
The latter approach seems reasonable perhaps with the addition of a detailed medication review on history.
Agree 100%
Curious if everyone LPs all these patients? I agree dx of UTI should be made cautiously but if truly “dx of exclusion” then we should be LPing all? I find that in practice if positive urine with nil else acute (minus LP) then provisional dx of UTI occurs, unless pt has a typical sx that points toward encephalitis.
I would be unlikely to do an LP in ER with this patient unless there was some convincing signs, and after ruling other illnesses or causes out.
I would spend time doing a through physical exam and initial testing with anything more probable – CXR, B’work and ACS workup, CT head, Urinalysis as my initial investigations
Complete clinical history
So many potential diagnoses from non-specific symptoms. Holy!
Excellent points
it is not as easy as it seems
great review
good review
for sure. I always consider SBO.
UTI or other infections?
Every time I read ‘poor historian’ I remember our professor in medical school who taught us that a historian is someone who RECORDS a history (us, the doctors), so when we say ‘poor historian’, we’re talking about ourselves!
Good point!
nice exercise for memory differential diagnosis
son pacientes altamente complejos
Very interesting differentials. I will definitely see my geriatric patients differently now. And the common UTI diagnosis will now be only after I’ve ruled out other more serious conditions.
🙂
Good review of atypical presentations!
normak
kkl
It is a good case of ER presentation which may challenge the brain to dig deep and try to find D/D and start clearing each one of them.
Agreed
Getting more precise information is critical to understanding what is going on. I like the idea of a UTI as a diagnosis of exclusion however, I have seen UTI get overlooked and patients sent home without doing a urinalysis and they come back
I think thats a good point. I’ve also see the opposite where a patient comes in with general weakness and is given the dx of Urosepsis because the CXR is normal and there is 1+ leuks in the urine. I also like the idea of UTI as a dx of exclusion for this reason. We need to rule-out the other many causes of this presentation
I find that depression screening can often get missed in the context of multiple medical conditions and poly-pharmacy but I always try to ask about past psych hx or any personal/social changes recently (ie loss of a loved one, recent anniversary of a death)
good point
I’m glad for the emphasis on using UTI as a diagnosis of exclusion. As mentioned, the majority of elderly have asymptomatic bacteriuria, and it seems that the majority of elderly presentations to the ER are attributed to UTI while other diagnoses may be overlooked.
how cystitis if neg urine?
How astute of you! However if you notice the stem doesn’t say “urine: negative” but “urine within normal limits!” “Urine WNL” in the elderly can include some WBCs even some bacteria. That finding doesn’t necessarily mean they have a urinary infection — but it also doesn’t mean that they don’t! This man probably has 2-3 + WBCs and nitrites positive. If you can’t find any other cause for his acute functional decline and subsyndromal delirium (which is probably what his “just not the same” is) then it might be reasonable to consider treating for urosepsis — but only after a careful consideration of all of the other possibilities.