Posted by: notdeaddinosaur | February 12, 2011

Clinical Quiz, Abridged (Contains Answer)

Patient presents with acute (overnight) onset of command auditory hallucinations, hearing voices telling her scary things. No family history of mental illness; denies illicit drug use; no fever, cough, urinary urgency/frequency/dysuria. Physical exam completely negative, including neuro.

Is it:

  1. Schizophrenia
  2. Drug OD
  3. Urinary tract infection

What’s that, you say? Why yes, I’ve left out a key piece of information: the patient’s age. What would you think if the patient were 23? 33? 73?

As it happens, the patient was 73. The head CT was normal for age (no stroke; no tumor) and the diagnosis was UTI. Downright spooky what those things can do to the elderly.



  1. See lots of it in my patients. Whenever I see an acute onset of altered status in the elderly I always think UTI…. Saves the NHS a fortune!

  2. Rereading your post, did you actually have a CT done of this pt Dino?(she asks incredulously)

  3. I bet she did, here in the US. CT’s get done right away, and if she hadn’t and there was stroke or anything, god help her in court. We’ll see what Dino says, but I think any sudden strange behavior like that will get you a head CT – probably standard of care. We’ll see if I’m right.
    Nothing says grandma can’t have a UTI and a stroke, brain tumor, etc. at the same time.

  4. When my 92-year-old mother hallucinates (she hears music), it’s always a UTI. I can tell it’s coming two weeks before anything shows up in lab work.

  5. That was my guess only because of working in an ED but had my own little surprize in July 2010…my darling hubby NO MEDICAL ISSUES taking no meds except ASA because we are 56 became repetativive in asking same questions over and over sort of “in a loop”.Speech clear,knew where we were,knew name etc.When I asked him if he felt ok he said “I’m confused”.I’m a nurse so I held it together but never had I seen anything like this.Into ED on stroke protocol we learned all about TGA,trans global amnesia.CT was first thing, ED doc missed it but I requested neuro even though CT was neg(so was everything else) neurologist knew right away.We still did MRI and several other tests.Scary for sure!

  6. At our local nursing home Septra Ds is the pysch drug of choice!

  7. I was asking -how old is the patient?! as I was scrolling down. You rock, Dino!

  8. have seen it in a client as young as 60 w/ mult. health issues. i work with elders at home and now pretty much try to include a little teaching on the importance of hydration AND the risk of UTI (which often shows up after underhydration – not drinking to avoid having an accident or having to use an unfamiliar bathroom) showing up as changes in mental status as the first symptom for ladies and gents alike. now if there were just an easy way to get a clean urine for culture testing on a not so mobile and not so cooperative older lady!

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