Subinternship Medicine · Year 4 · from Subinternship Medicine
Case 3: Overnight Decision-Making and Documentation
Clinical Image
Source: Wikimedia Commons - Medical Records - CC BY-SA 4.0
Case Presentation
At 3 AM, the sub-intern is paged about Mr. Williams, an 80-year-old with metastatic prostate cancer admitted for pain management. The nurse reports he is acutely confused and trying to get out of bed, which is new from his baseline. The sub-intern assesses him using a systematic approach. Vital signs: afebrile, HR 95, BP 140/85, O2 sat 96% on room air. Glucose is 145 (normal). She reviews medications: he received scheduled oxycodone 10 mg at midnight. Physical exam reveals urinary retention with 600 mL on bladder scan. She places a Foley catheter with immediate relief of 700 mL of urine. His confusion improves over the next hour. She considers the differential for acute delirium: the most likely cause is urinary retention (common cause, especially in elderly men on opioids), but she also checks for other reversible causes (infection, hypoxia, metabolic). She decides NOT to start an extensive overnight workup for his confusion given clear precipitant. She documents a cross-cover note: "Event: Acute confusion at 0300. Assessment: Found to have urinary retention (700 mL post-void residual) on bladder scan. Intervention: Foley catheter placed with immediate output of 700 mL. Response: Confusion improving at 0400 reassessment. Plan: Continue Foley, recommend AM urology consult and medication review given urinary retention likely exacerbated by opioids. Primary team aware via sign-out note." At sign-out in the morning, she provides a complete handoff of the overnight event.
Key Learning Points
- Acute confusion/delirium requires evaluation for reversible causes: medications (opioids, anticholinergics, benzodiazepines), infection (UTI, pneumonia), metabolic (glucose, sodium), hypoxia, urinary retention, constipation
- Cross-cover decision-making prioritizes safety and reversible interventions; defer complex workups or irreversible decisions to the primary team
- Cross-cover note elements: Event (what happened), Assessment (findings), Intervention (what was done), Response (how patient responded), Plan (follow-up needed)
- Thorough sign-out documentation ensures continuity; the day team should know exactly what happened overnight