Documenting a geriatric medicine round
Ward notes with the medication review and falls assessment, discharge summaries, and letters to the GP and family.
Day three of a delirium admission
Day three, delirium after a fall at home. 4AT 6 on admission, 2 today.
Likely causes: five days without a bowel action, and the oxybutynin she started a month ago. Urine dip positive but no urinary symptoms, not treating it.
Cease oxybutynin. Macrogol BD, bowels opened this morning.
Lying BP 138/72, standing 108/64 at three minutes and dizzy. Cease the doxazosin.
Walking with a four-wheeled frame. OT home visit before discharge. Cognitive screen once the delirium has cleared.
1. Delirium
4AT 6 on admission, 2 today. Precipitants: constipation (5 days), oxybutynin (started 1 month ago). Positive urinalysis without urinary symptoms: asymptomatic bacteriuria, not treated.
2. Falls
Postural drop: 138/72 lying, 108/64 standing at 3 min, symptomatic. Mobilising with a 4-wheeled frame.
Medication changes
- Oxybutynin ceased (anticholinergic)
- Doxazosin ceased (postural hypotension)
- Macrogol BD
Plan
- OT home visit before discharge
- Cognitive screen when delirium resolved
Letters home
- Discharge summary
- Each medication stopped, with the reason, so the GP does not restart it at the next script.
- Family update
- What delirium is, why it happened, what to watch for at home and when to call.
- Letter to the residential or community team
- Mobility aid, the falls plan and the outstanding cognitive assessment.
