Clinical Geriatrics

CASE PRESENTATION
A 75-year-old Haitian man presented to the emergency department (ED) with altered mental status (disoriented to time and place). Although a poor historian, he did report progressive worsening of vision in his eyes bilaterally over an approximate 2-week period. Past medical history included type 2 diabetes mellitus for approximately 6 years and hypertension. He was not compliant with medications for these chronic conditions as prescribed by his primary care physician and was taking no medications at the time of assessment in the ED. Social history was significant for alcohol use of 1-2 beers per day for numerous years up until 3 months previously. He denied tobacco or illicit drug use.

Review of systems was positive for polyuria, polydipsia, and generalized weakness, as well as the visual changes. He denied chest pain, shortness of breath, orthopnea, headache, or abdominal discomfort. On physical examination, the patient was afebrile. He had decreased bilateral visual acuity, scleral icterus, and a pterygium in the left eye. The buccal mucosa was dry, and he had poor dentition. He had tachycardia, with a regular heart rate of 110 beats/min, and heart sounds were distant. He was also tachypneic, with a respiratory rate of 24, and bibasilar crackles. On abdominal examination, the patient had positive bowel sounds in all four quadrants, no hepatojugular reflux, no organomegaly, and no pain, tenderness, or rebound elicited in any quadrants. His skin was jaundiced, dry, and intact. There was hyperpigmentation of his ankles bilaterally, but no ulcerations or bony deformities. Distal pulses were normal. On neurologic examination, he was awake and oriented x 1 (to person). Upper extremities revealed 5/5 muscular strength. Mild proximal lower-extremity weakness was evident at 4/5. Reflexes were normal throughout, as was dorsiflexion and plantar flexion.

The basic metabolic panel was within normal limits (WNLs). Sodium was borderline low at 132 mEq/L, but potassium, chloride, and carbon dioxide were WNLs. Renal compromise was evident, however, with blood urea nitrogen of 46 mg/dL and creatinine of 2.6 mg/dL. There were no previous levels with which to make a comparison. Glucose was elevated to 147 mg/dL. Albumin was low at 2.6 g/dL. On coagulation parameters, the partial thromboplastin time (PTT) was prolonged to 45 seconds. Erythrocyte sedimentation rate was only 5 mm/h. Liver function tests (LFTs) were elevated to the following: aspartate aminotransferase (AST) 151 U/L, alanine aminotransferase (ALT) 165 U/L, and alkaline phosphatase 572 U/L. A urinalysis showed protein 300 g/dL, glucose 250 mg/dL, large bilirubin, small blood, 2+ bacteria, 5-10 white blood cells, and trace ketones. A chest radiograph did not reveal any lung parenchymal abnormalities or infiltrates. A brain computed tomography (CT) scan showed bilateral white matter changes consistent with chronic microvascular disease.

The patient was diagnosed with two main problems on admission: delirium due to a urinary tract infection, and renal failure most likely prerenal in nature secondary to volume depletion. Orthostatics were borderline in the ED. The patient was hydrated with normal saline and started on levofloxacin. He was admitted to the acute geriatric unit, where his mental status improved, and he was placed on a sliding scale of regular insulin to control his diabetes. Nifedipine, and then a combination of metoprolol and minoxidil, were initiated to control hypertension. An ophthalmology consult was requested, and a diagnosis of glaucoma and mild diabetic retinopathy was later made. The patient was started on timolol and latanoprost/benzalkonium eyedrops, in addition to laser surgery being planned in the near future. A urine culture later came back with no growth, the infection likely having cleared with antibiotics before the culture was collected. Blood cultures were negative.