70 year old female with a two week history of urinary symptoms including; Increased frequency, dysuria, nocturia, urgency, dark cloudy urine, odorous urine and supra pubic tenderness. This patient has demetia and her son has lasting power of attorney . According to her medical notes Her son had a telephone consultation with her GP 8 days ago and was prescribed a course of Notrofurantoin, 100mg BD (twice daily for 7 days) – 14 tablets supplied. Since finishing these anti-biotics the patients symptoms have not improved, she has now developed increased confusion and a low grade fever (37.8) over the last 48 hours. Her son was consermed amd called the surgery requesting a home visit.
O/A- GCS 14 (E4) V(4) M(6), airway patent (patient was shouting at her carer), effort of breathing appeared normal, patient appeared well perfused: Skin was pink, slightly flushed in her cheeks.
The patient appeared agitated and was shouting at her carer, her son was present and told me she was Spanish, she was speaking in Spanish but what she was saying was not making any sense. Her son spoke both Spanish and English so this was helpful . The son had called the surgery as his mother seemed to confused to understand what was going on.
I introduced myself to the patient in English and asked her if it was ok to sit at her bedside. She then began shouting at her son in Spanish , her son told me she was asking why he had so many friends over. Her son explained that I was from her surgery and I had come to check her over, she calmed down significantly at this point and gestured for me to sit at her bedside. I asked (via her son) whether it was ok for him to give her a history/account of her illness while I take her observation (she agreed).
Skin: Normal colour, warm to touch, good elasticity (no sign of dehydration), CRT>2 seconds.
Pupils equal 3mm, round and reaction to light.
OBS: HR: 80, RR: 16, SPO2: 98%, Temp 37.8, CRT<2seconds, BM 7.8, B/P 142/78
Indicated for central nervous system assessment due to increased confusion. To rule out red flags such as TIA, CVA, alternative infection, head injury.
Abdo assessment due to urinary tract symptoms – assess for pain, swelling, masses, bruising/bleeding, posterior tenderness over kidneys, herniation.
I asked if the patient would be able/happy to pop to the toilet and provide a urine sample for me. She wore pads to increased risk of infection. Patient became visibly agitated, she began shouting in Spanish and her son said she was confused and shouting about people looking in through the windows . She then reached out and scratcher her carer on the arm. At this point I felt it best to give the patient some space and told her I would go and speak with her son in the living room. The carer stayed in the bedroom tring to calm the patient and encourage her to go to the toilet, the patient refused multiple times.
Due to the patients distress, confusion and physical aggression I deemed it safest to proceed discussion with son – discuss mental capacity assessment (did not have capacity).
Unable to obtain urine sample – left urine sample pot with carer and adv to try and obtain and drop at surgery when possible. Prescribe fosfomycin granules, single oral dose 3g. Review in 48 hours and repeat dose for up to 7 days or until we have culture results back from mid stream urine sample.
Form processed for microbiology MSU sample and left at reception to send when the carer drops off a urine sample.
Booked for BT in 3 days time (earliest apt) to identify presence of infection and assess the severity of infection also assess renal function which will aid in prescribing (if low egfr we are unable to prescribe certain medications).
UTI- dementia, language barrier, aggressive, lived with son, thre urine sample after going to the toilet- unable to take msu sample or dip test. Increased confusions – various uti symptoms, treat for uti with abx and req carers try to obtain msu for us asap and send off. Reassess after results are received and change meds/plan accordingly. Worsening advice given.
Discuss capacity assessment – ethics and legalities associated with this. Unable to gain consent from the patient due to her confusion- she lacked capacity, acted in patients best interest.
