Personal Details:
Name: Mrs Davies
Age: 70
Medical Record:
Past medical history: Hypertension, Depression.
Regular medication: Citalopram (for 5 months), Bendroflumethiazide.
Notes:
A 70-year-old woman has been brought to the Emergency Department by her daughter due to confusion that started this morning. She has a mild fever. The daughter is very concerned. The patient has consented for you to speak with her daughter.
Investigations:
Blood tests: Sodium 120 mmol/L (low), CRP is high (24). FBC, LFTS, U+E normal.
Urine dip negative
CT Head: Normal for age.
Examination is unremarkable, including chest, heart, and abdominal examination.
HR 91 T 37 RR 18 BP120/80 SPO2 98
Task:
1. Talk to the daughter and explain the situation.
2. Address her concerns and discuss the management plan.
Opening Sentence: “Doctor, what’s happening to my mum? I’ve never seen her like this. She doesn’t even recognise me.”
Open History (to give freely): “She was fine yesterday, but this morning she was just not making any sense. She seems a bit warm.”
ICE (Ideas, Concerns, Expectations):
Ideas: “I don’t know what’s wrong. It came on so suddenly.”
Concerns: “What happened to her? Is she going to be alright? Is this permanent?”
Expectation: “I want to know what’s wrong and that you can fix it.”
How to Act: You are anxious and very worried about your mother.
More History (only if asked): Your mother has no history of memory problems before today. She has been a bit thirstier than usual recently.
Social History: Lives independently.
Questions to ask:
What does the low salt mean?
Why has this happened?
Opening & Acknowledging Concern:
Hello, I’m Dr. [Name], one of the doctors in the Emergency Department. I can see how worried you are about your mum. Let’s talk through what’s been happening.
History of Confusion (from daughter):
You said the confusion started this morning. What was she like yesterday?
Can you describe the confusion? What was she saying or doing that was unusual?
Has she ever been confused like this before?
Medical History:
You mentioned she felt warm. Has she been shivery or sweaty?
Has she had a cough or sore throat? Any problems passing urine? Does she have to pee more often or rush to have a wee? Any change in urine colour or odour? Any sickness or vomiting?
Has she been moving her arms and legs as normal?
Can we go through her medications? You mentioned an antidepressant and a water tablet. How long has she been on them? Have we recently made any changes to her medication?
How has her mood been recently on the new antidepressant?
Apart from her hypertension and depression, does she have any other medical problems?
ICE (Ideas, Concerns, Expectations):
This has all come as a big shock. What were your own thoughts about what could be causing this?
What is your biggest fear right now?
What were you hoping we could do for your mum today?
Explain the situation, the likely diagnosis or DD:
Thank you for talking with me. I can see how worried you are, and it’s a very frightening situation. We’ve done some initial tests to find out what’s going on with your mother. The good news is that her CT scan of the brain is normal, so she hasn’t had a stroke. What she has is a condition called delirium, which is a sudden state of confusion.
Addressing and answering the patient’s ICE:
You’re worried this could be dementia. Delirium is different from dementia because it comes on very quickly and is usually reversible once we treat the cause. We have found two main causes for her confusion today. Firstly, her blood tests show a high level of an infection marker called CRP, which, along with her fever, tells us she has an infection somewhere in her body. Secondly, the level of salt, or sodium, in her blood is very low.
Next Steps:
The low salt level is the main reason for her confusion. We think this has been caused by a combination of her antidepressant, citalopram, and her water tablet, bendroflumethiazide. Both of these medications can, in some people, cause the body to hold onto too much water, which dilutes the salt in the blood. The infection has likely tipped her over the edge.
I think she needs to stay in the hospital. We will stop both the antidepressant and the water tablet for now. The main treatment for the low salt is to restrict the amount of fluid she drinks for a few days to allow the salt level to come back up naturally.
We need to find out the source of her temperature. She doesn’t have any temperature at the moment, but we will continue monitoring her temperature. If it goes up, we will take some blood tests to check for any infection in the blood.
I don’t see any clear indication for starting antibiotics now, but I will have a chat with one of my seniors for advice if this is something we need to consider.
Answer her questions
You asked if she will be alright. Yes, we expect her to make a full recovery. As the salt level returns to normal over the next few days, her confusion should completely resolve. We will monitor her very closely. Once she is better, we will need to talk to her GP about changing her medications to ones that are less likely to cause this problem in the future.
Have I made myself clear? Are there any questions?
Addressing ideas, concerns, and expectations: Clearly diagnose delirium and differentiate it from dementia. Explain the two underlying causes (possible infection and hyponatremia). Explain the link between the medications and the low sodium (SIADH/thiazide effect).
The management plan includes: 1. Admit to the hospital. 2. Stop the offending drugs (citalopram, bendroflumethiazide). 3. Discuss with a senior regarding starting antibiotics for the infection. 4. Implement fluid restriction. 5. Reassure the daughter that the condition is treatable and reversible.
What is scenario testing? This case tests the candidate’s ability to interpret blood results in the context of a clinical presentation and medication history. It requires knowledge of common causes of delirium and hyponatremia. The communication challenge is to explain a complex medical situation to a distressed relative in simple, reassuring terms.