Clinical Reasoning

The acute confusional state is defined by Mosby’s Dictionary of Medicine, Nursing and Health Professionals (2010) as “a form of delirium caused by an underlying biological/biomedical abnormality that interferes with the metabolic or biochemical processes essential for normal brain functioning.” Mr Douglas Adams, a 51 year old single gentleman who lives alone, has been admitted to hospital with confusion for investigation after being found by a visiting friend, confused and agitated at home. Following initial assessment, he has been admitted for further investigations. The following is a discussion on the probable hypotheses (in italics) and focused physical assessment pertaining to the next four hours of his hospital stay.

Is the patient experiencing the effects of silent myocardial ischaemia?

Silent myocardial ischemia is characterised by vague non- specific symptoms including, fatigue, dyspnoea or feelings of unease and is generally not associated with pain (Mc Cance, Heuther, Brashers & Rote, 2010). Diabetic neuropathy may also prevent the sensation of pain felt during a myocardial infarction (MI) (Fowler, 2011). Mr Adams has a number of risk factors associated with myocardial ischaemia including smoking, drinking alcohol, a BMI of 27,daily stress as a small business owner, hypertension (HTN) and is an insulin dependent type 1 diabetic (IDDM) (Li & Aronow, 2011). He has recently started exercising which can put unexpected strain on his cardiovascular system and cause myocardial ischaemia (Farrell & Dempsy, 2011). Dizziness, altered consciousness and irritability can be indicative of cardiovascular disorders as hypothesised by Farrell & Dempsy (2011) and Younk & Davis (2011), who propose that diabetics are four times more likely to be affected by cardiovascular disease.

Questions to ask Mr Adams in relation to this hypothesis so as to develop a more focussed physical assessment could include: Is there a family history of hypertension and diabetes?...