You Are the Current "On Call Physician" for Your Group

question 295

Multiple Choice

You are the current "on call physician" for your group, when you receive a call regarding one of your nursing home patients. The nurse reports that one patient has been acting strangely for the last few hours and is agitated at times.  This patient is an 82-year-old female who has been in the nursing home for the last two years, and has always been very pleasant. You know her very well from your recent nursing home visit. She has a past medical history of hypertension, diabetes mellitus, osteoporosis, and Alzheimer's dementia. Her daily medications are amlodipine, metformin, calcium - vitamin D, and donepezil. You are concerned that something is not right with the patient.
A CT scan of the patient's head is normal. Initial lab studies reveal the presence of a urinary tract infection with mild prerenal azotemia. You start the patient on empiric antibiotic therapy and intravenous fluids; however, the patient's mental status remains unchanged. You provide a bedside sitter for the patient for constant supervision. The sitter reports that the patient is very combative now. She has been trying to get out of bed and has twice attempted to pull her IV line out. She resisted the physical restraints that the nurse was trying to apply. Frequent orientation and reassurance has not improved her behavior. Which of the following is the most appropriate next step in the management of this patient?

• A)Give low dose haloperidol
• B)Give low dose lorazepam
• C)Order physical restraints to prevent injury anyway
• D)Provide another sitter for the patient
• E)Perform lumbar puncture

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