What is the best course of action for an elderly patient with a history of hypertension, who has lost her blood pressure medication, presents with a persistent sore throat despite a 5-day course of Amoxicillin, and is exhibiting confusion and cognitive impairment?

Immediate Management of Elderly Patient with Lost BP Medication, Persistent Sore Throat, and Acute Confusion

This patient requires urgent evaluation for delirium with immediate assessment for life-threatening causes including stroke, infection, and hypertensive emergency, while simultaneously addressing the lost blood pressure medication. 1

Priority 1: Address the Acute Confusion (Delirium)

The confusion and repetitive questioning represent acute delirium until proven otherwise and demand immediate systematic evaluation. 1

Immediate Delirium Workup

• Perform validated delirium screening using the two-step Brief Confusion Assessment Method, as confusion in elderly patients with bacteriuria and without focal genitourinary symptoms requires assessment for other causes rather than immediate antimicrobial treatment 1

• Check vital signs immediately, including orthostatic blood pressures (drop of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing), as the patient has lost her BP medication and may have developed hypertensive emergency or severe hypotension 2

• Obtain urgent neuroimaging (brain MRI preferred, CT if MRI unavailable) to exclude acute stroke, hemorrhage, or other structural lesions, as any sudden neurological change warrants immediate investigation 3

Common Causes to Evaluate

• Infections are the most common reversible cause of delirium in elderly patients, with urinary tract infection and pneumonia being most frequent 1

• Medication-related causes including the abrupt discontinuation of antihypertensive medications can precipitate delirium 1

• Electrolyte disturbances, particularly hypophosphatemia, hyponatremia, and hypokalemia, can cause acute psychotic changes and delirium in elderly patients 1

Priority 2: Evaluate the Persistent Sore Throat

A sore throat persisting after 5 days of amoxicillin with negative rapid testing requires reassessment for alternative diagnoses, not additional antibiotics. 4, 5

Critical Red Flags to Exclude

• Assess for "red flag" symptoms including severe dysphagia, drooling, stridor, respiratory distress, or inability to swallow secretions that would indicate supraglottitis or deep space infection requiring urgent ENT consultation 4

• Examine for temporal tenderness, jaw claudication, or scalp pain, as these symptoms in an elderly hypertensive patient mandate immediate ESR and C-reactive protein testing to evaluate for giant cell arteritis 1

• Consider atypical presentations of serious disease, as throat pain can rarely represent aortic dissection or other cardiovascular emergencies in patients with hypertension 6

Diagnostic Approach

• Perform complete throat examination looking for peritonsillar abscess, retropharyngeal abscess, or other structural abnormalities that would explain persistent symptoms despite antibiotics 4

• Obtain chest X-ray if any respiratory symptoms are present, as pneumonia can present with referred throat pain and would explain both the persistent symptoms and delirium 1

• Do not prescribe additional antibiotics without clear evidence of bacterial infection, as the negative rapid testing and lack of response to amoxicillin suggest viral etiology or non-infectious cause 5, 7

Priority 3: Address the Lost Blood Pressure Medication

Immediately check blood pressure and assess for hypertensive emergency versus medication withdrawal effects. 1

Blood Pressure Assessment

• If blood pressure is severely elevated (>180/120 mmHg) with symptoms, this constitutes a hypertensive emergency requiring immediate intervention with titratable IV antihypertensive agents in an intensive care setting 1, 8

• If blood pressure is severely elevated without acute end-organ damage, this is hypertensive urgency and can be managed with oral antihypertensives, but avoid rapid reduction that could precipitate stroke or myocardial ischemia 1, 8

• If blood pressure is normal or low, assess for orthostatic hypotension as a cause of confusion and weakness, which would require volume resuscitation rather than antihypertensive restart 2

Medication Replacement Strategy

• Restart blood pressure medication at previous dose once acute issues are stabilized and blood pressure warrants treatment, with close monitoring for the first 24-48 hours 1

• Provide patient education on medication adherence and consider pill organizers, pharmacy auto-refill programs, or simplified regimens to prevent future medication loss 1

Diagnostic Testing Algorithm

Order the following tests immediately: 1

• Complete blood count, comprehensive metabolic panel (including sodium, potassium, phosphate, glucose, creatinine)
• Urinalysis and urine culture
• Chest X-ray
• 12-lead ECG
• Brain imaging (MRI preferred, CT acceptable)
• ESR and C-reactive protein if any scalp tenderness, jaw claudication, or vision changes

Critical Pitfalls to Avoid

• Never attribute confusion to "just being old" or to the sore throat alone - delirium always has an underlying cause that must be identified 1

• Do not assume the sore throat is the cause of confusion and treat with more antibiotics without proper evaluation, as elderly patients with bacteriuria and delirium require assessment for other causes 1

• Avoid rapid blood pressure reduction if hypertensive, as this can worsen cerebral perfusion and cause stroke, particularly in elderly patients with chronic hypertension 1, 8

• Do not discharge this patient until the cause of confusion is identified and improving, as delirium in elderly patients is associated with increased mortality and need for nursing home placement 1

Disposition

This patient requires hospital admission for comprehensive evaluation of delirium, management of blood pressure, and monitoring until mental status returns to baseline 1