Confusion / Delirium OSCE - UTI-Induced Delirium | Free OSCE Practice

Case Overview

Age/Sex: 61/F
Occupation: Retired school secretary
Setting: Emergency department brought in by daughter after being found confused at home
Chief complaint: "She's confused and not herself"

Patient Script

Who I Am

I'm 61, I used to work in an office, and I live at home with my daughter who visits most days.

What Brings Me In

"My daughter says I've been confused today — I don't know what day it is and I feel 'off'."

My Story

I woke up yesterday feeling a bit tired and not sleeping well. Over the last 24 hours I've been more forgetful than usual and this morning my daughter noticed I was disoriented and very slow to answer questions. I felt a little warm last night and had some chills, but I didn't have a big temperature that I noticed. I haven't been out of the house this week. I have had some mild discomfort when I pass urine on and off for a while but I thought that was just me being older. I had a bad back flare last week and started a new pain tablet two days ago, which I took last night. I haven't had any weakness down one side or trouble speaking.

My Medical Background

Past medical history: Type 2 diabetes (diagnosed 12 years ago), hypertension, chronic kidney disease stage 3, osteoarthritis with chronic back pain
Regular medications: Metformin 500 mg twice daily, gliclazide 60 mg once daily, lisinopril 10 mg daily, atorvastatin 20 mg nightly, paracetamol PRN, recently started on oxycodone 5 mg PRN two days ago (took it last night)
Allergies: Penicillin (rash years ago)
Social: Lives at home with daughter; ex-smoker (stopped 10 years ago); drinks 0–2 units alcohol/week
Family history: Mother had type 2 diabetes; father had heart disease

What I Think & Worry About

"I'm worried something serious is wrong with my memory — maybe I'm having a stroke or getting dementia."
"I just want to understand why I'm so muddled today."
"I hope it's not something the new pain tablets caused."

If You Ask Me About Other Symptoms...

"I feel a bit sweaty and had a bit of a fever last night, but I don't remember checking my temperature."
"My tummy is fine, I haven't been vomiting and I can eat a little."
"I sometimes leak a bit when I cough, that's been going on for a while." (chronic urinary stress incontinence)
"No chest pain, but I had a small cough last week that went away." (recent upper respiratory symptoms — red herring)
"I get dizzy sometimes when I stand up but that happens occasionally and isn't new." (orthostatic symptoms — distractor)
"My pee sometimes stings but not always; I thought it was from my bladder being sensitive." (possible urinary symptom but vague)

Clinical Summary

Examination

General: Alert but disoriented to time and place, intermittently inattentive; GCS 14 (E4 V4 M6)
Vitals: Temperature 38.1°C, HR 102 bpm, BP 128/76 mmHg, RR 18/min, SpO2 97% on room air, capillary blood glucose 14.2 mmol/L
Cardiovascular: Regular tachycardia, no murmurs
Respiratory: Clear breath sounds, no crackles
Abdominal: Soft, non-peritonitic, no palpable masses
Neurological: No focal limb weakness, pupils equal and reactive, speech slightly slowed but intelligible, attention tests impaired (cannot recite months backwards)
GU: Mild suprapubic tenderness on deep palpation; no obvious CVA tenderness

Investigations

Bedside capillary glucose: 14.2 mmol/L (hyperglycaemia, chronic diabetic)
Urinalysis (dipstick): Leukocyte esterase ++, nitrites +, blood trace
Bloods: WCC 12.8 x10^9/L (mild leukocytosis), CRP 48 mg/L (moderately elevated), Na 138 mmol/L, K 4.4 mmol/L, creatinine 160 µmol/L (baseline ~140 µmol/L), eGFR ~42 mL/min/1.73m2
Blood cultures: sent (pending)
Chest X-ray: clear with mild bibasal atelectatic changes (no focal consolidation) — likely non-contributory
CT head (non-contrast): no acute intracranial haemorrhage or large infarct (performed because of acute change in mental status) — normal
Urine culture: sent (pending)

Diagnosis

Primary diagnosis:

UTI-induced delirium (acute delirium in an older diabetic patient with acute onset confusion, fever, positive urinalysis, mild leukocytosis, and suprapubic tenderness)

Differential diagnoses:

Medication-induced delirium (recent initiation of oxycodone; opioids can worsen cognition) — plausible contributor given timing
Metabolic causes (hyperglycaemia) — glucose elevated but not at levels typically causing severe encephalopathy; electrolytes largely normal
Sepsis from other sources (e.g., pneumonia) — CXR not supportive and respiratory exam unremarkable
Cerebrovascular event (stroke) — CT head normal and no focal neurological deficit makes this less likely
Underlying dementia with acute exacerbation — no prior baseline cognitive impairment reported; acute onset supports delirium

Management

Immediate safety and supportive care: ensure patient in a safe, well-lit environment, reassure and reorient frequently; involve family
Review and stop/hold potentially deliriogenic medications: withhold oxycodone and review need for other sedating agents
Treat underlying infection: obtain urine culture and start empirical antibiotic therapy appropriate for suspected UTI and renal function (e.g., IV ceftriaxone 1 g once daily adjusted per local guidelines and penicillin allergy history to be considered — choose agent mindful of penicillin allergy and CKD)
Fluid management: cautious IV fluids if clinically indicated, monitor urine output and renal function given CKD
Monitoring: regular observations (including temperature and blood glucose), repeat bloods as clinically indicated, reassess mental status frequently
Further investigations as indicated: continue culture results and tailor antibiotics; consider review by geriatrics or liaison psychiatry if delirium persists
Follow-up: review medications, consider bladder scan if retention suspected, arrange community support and follow-up once delirium resolves

Key Learning Points

Older adults often present with UTI as acute delirium rather than typical urinary symptoms; always consider infection in new-onset confusion.
Identify and remove reversible contributors to delirium (recent opioids, metabolic disturbances, dehydration), while treating the underlying cause.
Systematic assessment (ABCs, targeted exam, basic labs, urine studies) and early urine culture guide appropriate antibiotic therapy; avoid premature anchoring on dementia or stroke without focal signs.