A&E (If so why) or alternative care pathway?

You are called to 81 year old female, with hypertension. Call is placed by the son - ?Learning difficulties.

On arrival to the private property, you notice it is notably cluttered and disorganised, but you can move and don't foresee massive access problems.

You are met by the patient at the door who asks you to come in. There are no obvious ABCD concerns on initial presentation (note patient is alert and orientated to time and place). She doesn't sit down, appears restless and immediately starts to tell you about her myriad of medical aliments while walking around looking for her electronic blood pressure machine, with the cuff still on her arm.

Initially it is unclear as to why you have been called and needs active voice coaching to calm her down to establish and initial presenting complaint. She states she thinks last night she was unwell because her own Blood Pressure machine said ERR (Error). Upon asking what her BP was she says 90, but appears unsure and confused has no idea if this is Systolic or Diastolic. You note some occasional stumbling.


After much story telling and digression on patients behalf, you establish she has been diagnosed with hypertension for "years", has had hiatus hernia for "years" and has ongoing problems with gastric reflux stating this has been also going on for years and it burns her mouth.

She has multiple bags of various medications (still in pharmacy paper bags such as boots etc.) Some are old prescriptions, some new - certainly polypharmacy however it is unclear from asking her which drugs she currently takes. She becomes panicked and distracted when she realises her "nasal spray" is not there, only to find it in her handbag a short while later. Notable drugs include: GI relaxants, HTN meds, and OTC Painkillers.

The patient later states she is worried about her health, is anxious and believes the nurses in hospitals doctors don't believe her pain's and illnesses - this is a constant repetitive theme throughout this patient contact.

Note - Fast Negative, No Trauma, No Urological.

Initial impressions: Underlying medical condition causing confusion?; Undiagnosed MH?; Anxiety - MH?

My question - what other considerations to this job might you take? Is A&E an appropriate NHS care pathway for the above patient? What is your primary concern?