The Patient, an 86-Year-Old Woman Referred by Emergency Dept

Presenting problem: found on floor: no meaningful history from patient as drowsy and not able to recall event.

From a residential care home, collateral: found on floor at 4 am. Last seen at 2 am in bed. Found right side and urinary incontinent at that time. Reduced appetite for last 24 hours and reports nausea. Bowels last opened two days ago.

Independently mobile. Requires supervision and prompting to feed self and wash and dress. Occasionally urinary incontinent and wears pads overnight. Continent with bowels. Usually disorientated but able to hold a conversation and answer aptly yes/no. But poor memory. Been at home for three years. No issues otherwise.

Past medical history: recurrent UTI/Alzheimer's dementia/hypertension/stroke

Medications: co-codamol 30/500 TT QDS (initiated two months ago following fall and right shoulder injury), bendroflumethiazide 2.5 mg, OD atenolol 50 mg, OD donepezil 10 mg OD, aspirin 75 mg OD, simvastatin 40 mg, OD trimethoprim 100 mg ON.

Examination: Clinically dehydrated (reduced skin turgor/dry mucous membranes) CVS: lying BP 105/64 mmHg. Too drowsy to stand. HR 54/min regular (confirmed on ECG). Neuro: alert and disorientated. Nil else focal. AMTS = 2/10. Resp: clear lung fields. GI: abdomen: soft, BS present: lower abdominal discomfort on palpation. PR: loaded rectum. Urinary: palpable bladder. Joint: bruised right shoulder, movement preserved in all four limbs. No bony/spinal tenderness. No sores seen.

Investigations: bladder scan: 710 mLs (post void residual) U&E: eGFR 24 (baseline 56). Urine dip +ve Previous MSU: resistant to trimethoprim. CK/Bone/LFT/FBC/TSH/Haematinics: normal ranges. CT head (fall and confusion): disproportionate hippocampal atrophy and moderate burden of small vessel disease. Mature infarct noted right temporoparietal lobe.