A 76-year-old man is brought to the hospital due to a 1-day history of confusion. For the past 3 days, he has also had nasal congestion, sore throat, and a non-productive cough. Family members say that he has been acting strangely, asking the same questions repeatedly, talking to his deceased brother, and getting out of bed multiple times at night. The patient has a history of hypertension and benign prostate hyperplasia. His medications include amlodipine, tamsulosin, and over-the-counter cold medicine. He does not use tobacco, alcohol, or illicit drugs.
His temperature is 37.2 C (99 F), blood pressure is 140/80 mm Hg, and pulse is 92/min. On examination, the patient appears to be in distress and is disoriented. Moderate pharyngeal erythema without exudate is present. Cardiopulmonary examination is normal. The abdomen is soft with tenderness and a palpable mass in the suprapubic region. His prostate is enlarged and smooth. There is no neck rigidity and he moves all extremities with equal strength. Laboratory results are as follows:

Which of the following is the most appropriate next step in management of this patient?

Question

A 76-year-old man is brought to the hospital due to a 1-day history of confusion.  For the past 3 days, he has also had nasal congestion, sore throat, and a non-productive cough.  Family members say that he has been acting strangely, asking the same questions repeatedly, talking to his deceased brother, and getting out of bed multiple times at night.  The patient has a history of hypertension and benign prostate hyperplasia.  His medications include amlodipine, tamsulosin, and over-the-counter cold medicine.  He does not use tobacco, alcohol, or illicit drugs.
His temperature is 37.2 C (99 F), blood pressure is 140/80 mm Hg, and pulse is 92/min.  On examination, the patient appears to be in distress and is disoriented.  Moderate pharyngeal erythema without exudate is present.  Cardiopulmonary examination is normal.  The abdomen is soft with tenderness and a palpable mass in the suprapubic region.  His prostate is enlarged and smooth.  There is no neck rigidity and he moves all extremities with equal strength.  Laboratory results are as follows:

Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This elderly patient has delirium associated with acute urinary retention. In a patient with underlying benign prostate hyperplasia, sympathomimetics (eg, pseudoephedrine) or antihistamines with anticholinergic properties (eg, diphenhydramine) in cold medications can precipitate acute urinary retention. Urinary retention with increased bladder tension likely stimulates the sympathetic nervous system, resulting in catecholamine release and consequent delirium. Patients often have confusion and/or agitation but may not experience abdominal discomfort or specific urinary symptoms. Physical examination can demonstrate a distended bladder with discomfort on deep suprapubic palpation. The diagnosis of acute urinary retention can be confirmed with bladder ultrasound showing urine volume >300 mL. Patients with a highly suggestive history and physical examination can proceed directly to urinary catheterization as it is both diagnostic and therapeutic. Symptoms typically resolve rapidly after bladder decompression. (Choice A) This patient's abdominal examination findings are strongly suggestive of urinary retention with bladder distension; CT scan of the abdomen/pelvis may not be necessary as urinary catheterization may resolve his symptoms. (Choice B) Respiratory fluoroquinolones such as moxifloxacin can be used for outpatient treatment of community-acquired pneumonia. This patient has a normal cardiopulmonary examination and no evidence of fever, dyspnea, or pleuritic chest pain, making pneumonia less likely. (Choice C) Intravenous fluids can be helpful in dehydrated patients with delirium but would not address this patient's urinary retention. (Choice D) Lumbar puncture may be performed in patients with altered mental status and suspected meningitis or encephalitis. However, the absence of fever, headache, and nuchal rigidity makes these less likely. Educational objective: Acute urinary retention is an important cause of delirium in the elderly, although these patients often do not develop abdominal discomfort or specific urinary symptoms. Rapid resolution of symptoms typically occurs after bladder decompression. __________ References: Drug-induced urinary retention: incidence, management and prevention. (http://www.ncbi.nlm.nih.gov/pubmed/18422378)

A 76-Year-Old Man Is Brought to the Hospital Due to a 1-Day