History Taking · Foundation · Urology

Acute Confusion in an 82-Year-Old Woman

Practise this PLAB 2 history taking station on Urinary Tract Infection with Delirium. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in an acute medical unit. Mrs Barbara Haynes, an 82-year-old woman, has been admitted via accident and emergency with acute confusion. Her daughter reports she was well yesterday but this morning was disoriented and agitated. Urine dipstick shows nitrites, leukocytes, and blood. Please take a focused history to assess for urinary tract infection as cause of delirium and determine appropriate management.

Background notes: PMH: T2DM, Hypertension, Atrial fibrillation, Previous stroke, Osteoporosis

What this station tests

  • Distinguishing delirium from dementia through collateral history: acute onset with preserved prior cognition is delirium
  • Identifying UTI as the commonest cause of delirium in elderly patients
  • Non-pharmacological delirium management: familiar objects, reorientation, lighting, avoiding sedation
  • Communicating with the family: reassuring the daughter that this is not dementia and is expected to resolve
  • Screening for other delirium precipitants: medications, constipation, pain, dehydration, hypoglycaemia

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Acute confusion in an elderly patient requires the candidate to distinguish delirium from dementia, identify the precipitant (UTI in this case), and communicate with both the patient and their family. Mrs Haynes is 82, admitted with acute confusion since this morning. She was completely well yesterday. Her daughter Jane is the main historian. Open with: 'Jane, I can see your mum is not herself. Can you tell me exactly what has changed and when?' The collateral history is the diagnostic tool.

Core approach

Establish delirium versus dementia through the daughter. Baseline: completely independent, sharp, manages her own finances, active in community groups. Onset: acute, overnight. Yesterday she was normal, this morning she was disoriented, agitated, not recognising her surroundings. This acute onset with preserved prior cognition is delirium, not dementia.

Identify the precipitant. Urine dipstick is positive for nitrites and leukocytes. She has had increased urinary frequency, some incontinence, and her daughter noticed her urine smelled strong yesterday. In an 82-year-old, UTI is the commonest cause of acute delirium. Screen for other precipitants: new medications, constipation, pain, dehydration, recent fall, hypoglycaemia (she has diabetes).

Assess her current state. Is she agitated or hypoactive? Can she follow simple commands? Is she in pain? Check for urinary retention (common in elderly with UTI). Check blood glucose (she is diabetic). Check observations for sepsis (fever, tachycardia, hypotension).

Her daughter is extremely worried and asking: 'Is this dementia? Will she come back to normal?' This is the core interpersonal challenge.

Closing and safety netting

Reassure the daughter: 'Jane, your mum does not have dementia. This is delirium, which is an acute confusion caused by an infection. The urine test shows she has a urinary tract infection, and in older people, infections can cause this kind of sudden confusion. With antibiotic treatment, we expect her to return to her normal self over the next few days.'

Management: antibiotics for UTI (based on local sensitivities, considering her CKD and medication interactions). IV fluids if dehydrated. Blood glucose monitoring. Check renal function. Avoid sedation unless patient is at risk of harming herself (sedation worsens delirium). Non-pharmacological delirium management: familiar objects, consistent staff, reorientation, adequate lighting, sleep-wake cycle preservation.

Safety net: 'If her confusion worsens, she develops a high fever, or she becomes very drowsy, the team will escalate care.' Address discharge planning early: she should not return home until cognition has returned to baseline. Follow-up cognitive assessment at 4 to 6 weeks post-discharge.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for urinary tract infection with delirium. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Collateral history from daughter. Baseline cognition established (normal yesterday). Acute onset confirmed. UTI identified as precipitant. Other precipitants screened. Sepsis observations checked.

Costs marks: Not using collateral history. Not establishing baseline. Missing UTI as cause. Not screening other precipitants.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Antibiotics for UTI. IV fluids if dehydrated. Non-pharmacological delirium management. Avoiding sedation. Blood glucose monitoring. Discharge only when cognition returns to baseline. Post-discharge cognitive follow-up.

Costs marks: Sedating the patient. No antibiotics. No delirium management plan. Discharging while still confused.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Reassuring daughter that this is not dementia. Explaining delirium and expected recovery clearly. Acknowledging the daughter's distress. Communicating with the patient gently despite confusion.

Costs marks: Suggesting dementia. Not reassuring the daughter. Speaking only to staff, not to patient or family. Being dismissive of the daughter's concern.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Diagnosing dementia. An 82-year-old who was completely well yesterday and is confused today has delirium, not dementia. Candidates who suggest dementia without establishing the acute onset cause unnecessary distress and are clinically wrong.
  2. Sedating the patient. Benzodiazepines and antipsychotics worsen delirium. Candidates who prescribe sedation as first-line management for agitation demonstrate inappropriate management. Non-pharmacological approaches come first.
  3. Not using collateral history. The patient is confused and cannot provide a reliable history. The daughter is the key informant. Candidates who try to take a history solely from the patient waste time and get unreliable information.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How should I structure the urinary tract infection with delirium history in this PLAB 2 station?

Acute confusion in an elderly patient requires the candidate to distinguish delirium from dementia, identify the precipitant (UTI in this case), and communicate with both the patient and their family. Mrs Haynes is 82, admitted with acute confusion since this morning. She was completely well yesterday.

What are examiners marking in this urinary tract infection with delirium station?

Marks are won for: Collateral history from daughter. Baseline cognition established (normal yesterday). Acute onset confirmed. UTI identified as precipitant. Other precipitants screened. Marks are lost for: Not using collateral history. Not establishing baseline. Missing UTI as cause. Not screening other precipitants.

What is the most common mistake candidates make in this urinary tract infection with delirium station?

Diagnosing dementia. An 82-year-old who was completely well yesterday and is confused today has delirium, not dementia. Candidates who suggest dementia without establishing the acute onset cause unnecessary distress and are clinically wrong.

How do I prepare for this station if I have not managed urinary tract infection with delirium in clinical practice?

Structure beats experience here. Focus on identifying UTI as the commonest cause of delirium in elderly patients. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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