The selected disease process is cirrhosis which is a liver disease that occurs when scar tissue replaces healthy tissue preventing the organ from working normally. An injured tissue is replaced by a scar, known as fibrosis which often takes months or years of ongoing injury. The underlying pathophysiological mechanism of cirrhosis is the development of scar tissue that leads to the replacement of normal liver parenchyma causing blockage of portal blood flow and disruption of normal liver function. When fibrosis reaches a point where distortion of the hepatic vasculature occurs, it is called cirrhosis (Jagdish et al., 2023). If the damage continues, panlobular cirrhosis may occur. The cellular mechanisms responsible for cirrhosis are similar irrespective of the type of initial insult and the injury site within the liver lobule. The clinical manifestation observed in Bayani’s case that could be explained by the pathophysiological mechanisms of cirrhosis is foul-smelling urine. This is due to the liver’s inability to filter waste products effectively leading to a build-up of ammonia in the blood causing a strong, ammonia-like odor in the urine.

The clinical manifestations of cirrhosis depend on the advancement of the disease. The common early signs and symptoms are fatigue, loss of appetite, nausea, weight loss, itchy skin, and upper abdominal pain (Wu et al., 2024). The later signs and symptoms related to portal hypertension and declining liver function are vomiting blood, disruption in the menstrual cycle, jaundice, gallstones, dark-colored pee or stool, edema, blood in the stool, low urine output, shortness of breath, ascites and digestive difficulties. In Bayani’s case, the clinical manifestations that can partially support a diagnosis of cirrhosis are foul-smelling urine, abdominal pain which is caused by a buildup of fluid in the abdomen (ascites), and mild confusion which occurs when a damaged liver cannot properly filter toxins causing them to build up in the brain leading to cognitive changes.

The diagnostic tests that would be most appropriate for investigating a diagnosis of cirrhosis in Bayani’s case are physical examination, blood tests, imaging tests, and liver biopsy. A physical examination focuses on checking the medical history of Bayani, and the signs and symptoms related to cirrhosis. The blood tests for the disease include CBC, liver tests, and viral infection tests. For instance, liver tests can measure liver products like enzymes, proteins, and bilirubin levels in the blood to confirm cirrhosis. Imaging tests include MRI, CT scan, and abdominal ultrasound that show detailed images of the size, shape, and texture of the liver to confirm cirrhosis (Wu et al., 2024). A liver biopsy is a small procedure that involves taking a sample of the liver for examination to diagnose cirrhosis. Type 2 diabetes is a condition that causes high blood sugar levels because the body does not produce adequate insulin. In Bayani’s case, the clinical manifestations that can partially support the diagnosis of type 2 diabetes are mild confusion often known as brain fog, abdominal pain, frequent water drinking and urination, and foul-smelling urine due to the production of ketones excreted in the urine.

References

Jagdish, R. K., Roy, A., Kumar, K., Premkumar, M., Sharma, M., Rao, P. N., Reddy, D. N., & Kulkarni, A. V. (2023). Pathophysiology and management of liver cirrhosis: From Portal hypertension to acute-on-chronic liver failure. Frontiers in Medicine, 10. https://doi.org/10.3389/fmed.2023.1060073Links to an external site.

Wu, Z., Chen, L., Chen, J., & Chen, C. (2024). Management of liver cirrhosis and its complications. Liver Cirrhosis and Its Complications – Advances in Diagnosis and Management. https://doi.org/10.5772/intechopen.1005466Links to an external site.

 

I have seen this so many times in my career.  Family members even become clued in that their family member is probably having a urinary tract infection because of their confusion.

General Question:  How could an infection, such as a urinary tract infection (UTI) lead to confusion in an older adult?  What physiological changes might explain this? 

please see attachment

Directions: Read over the SOAP note and formulate a primary diagnosis.  Based on the diagnosis complete the SOAP note with the details that would be expected for the diagnosis. Use UptoDate and/or Dyna MedPlus to find out what is expected from the history and physical, diagnostic workup and management for the diagnosis. Include other peer review resources and and journal articles to support the development of your SOAP note. Complete and attach the evaluation & management score sheet to show how you coded the note for billing in each section.

Case Study: A 32-year-old woman presents for evaluation of a lump that she noticed in her right breast on self-examination. She says that while she does not perform breast self-examination often, she thinks that this lump is new. She denies nipple discharge or breast pain, although the lump is mildly tender on palpation. She has never noticed any breast masses previously and has never had a mammogram. She has no personal or family history of breast disease. She takes oral contraceptive pills (OCPs) regularly, but no other medications. She does not smoke cigarettes or drink alcohol Links to an external site.. She has never been pregnant. On examination, she is a well-appearing, somewhat anxious, and thin woman. Her vital signs are within normal limits. On breast examination, in the lower outer quadrant of the right breast, there is a 2-cm, firm, well-circumscribed, freely mobile mass without overlying erythema that is mildly tender to palpation. There is no skin dimpling, retraction, or nipple discharge. While no other discrete breast masses are palpable, the bilateral breast tissue is noted to be firm and glandular throughout. There is no evidence of axillary, supraclavicular, or cervical lymphadenopathy. The remainder of her physical examination is unremarkable.