Most Difficult Case Conference - American Geriatrics Society

FELLOW’S MOST
DIFFICULT CASE
AGS Annual Conference
May 3, 2013
Masoumeh Kiamanesh, MD
Madeline Dunstan, MS, CSA
1

“AN OLDER MAN AT
EITHER
HOSPITAL OR SNF IN
2012”

Chief Complaint/ HPI
Urinary tract Infection
72 year old Caucasian male was admitted to
hospital for sepsis, from urinary source with
suprapubic catheter in place and purulent
discharge around site.
He received 10 day course of IV Zosyn and was
then discharged to our SNF

HPI (cont.)
He is virtually nonverbal and so he could not
provide history. Patient’s daughter provided the
history.
His history goes back to 12 months ago when he
had a fall and since then he has been either at
the hospital (7 different hospitals) or SNF
(different facilities). He has not been discharged
to home for the past year.

HPI (cont.)
Patient was fully functional and independent in all his
ADL’s and IADL’s up to January 2012.
He had 2 falls in January 2012 and since then his function
declined, subsequently he was discharged to a SNF.
In May 2012 he was readmitted with UTI and sepsis. Then
he had multiple hospital admissions due to sepsis,
dehydration, UTI, and/or delirium. He was admitted to
multiple different settings including ICU, Gero-psych,
urology service and received multiple consults with
specialties including neurology, surgery.

HPI (cont.)
He eventually became non-ambulatory,
extremely weak, and unable to effectively
communicate. He was dependent in all his ADL’s
and IADL’s
He also had difficulty swallowing and failed
swallow tests and PEG tube was placed
He had urinary retention and had Foley Catheters
for 10 months replaced by suprapubic catheters

Past Medical History
Bipolar disorder
Parkinsonism
Dementia
HTN
Multiple UTI’s
Sepsis
Failure to Thrive
Multiple episodes of Ileus
Decubitus Ulcer stage II in sacral area

Family and Social History:
His father had hypertension
Remote history of smoking; No hx of
alcohol or drug use
He served in the US Coast Guard; worked
as a clerk for the Rail Road for 32 years
Daughter is Durable Medical Power of
Attorney; she is studying psychology at a
local university

Family and Social History:
Patient lived with his only child, a daughter;
He was separated for years. His house was
demolished after a flood in December
2011. They lived in a hotel since
Daughter states her mother died suddenly
in May 2012. Her parents were separated
and all she has is her father

Diet:
TF JEVITY 1.5 KCAL/ML at 60 mL/hr continuous
TF PRO-STAT Instill 1 Packet into tube, once a
day
He takes medications by mouth
Allergy: NKDA

Medications:
1. Carbidopa-levodopa 25-250 mg PO 3 Times Daily
2. Valproate Acid 250 mg PO Every 12 Hours
3. Olanzapine 5 mg PO Twice Daily
4. Lorazepam 0.5 mg POTwice Daily
5. Duloxetine 60 mg PO Once a Day
6. Donepezil 10 mg PO at Bedtime
7. Scopolamine 1.5 mg Patch Every 72 Hours
8. Trazodone 50 mg PO at Bedtime
9. Mirtazapine 30 mg PO at Bedtime
10. Quetiapine 50 mg PO at Bedtime.
11. Dronabinol 5 mg PO Twice Daily
12. Tramadol 50 mg PO every 6 Hours PRN
13. Oxycodone 5 mg PO 3 Times Daily

Medications (cont.)
14. Lubiprostone (AMITIZA) 24 mcg PO CAPS 2 Times
daily
15. Lansoprazole 30 mg PO Every Morning
16. Senna 6.5mg; QHS
17. Simethicone 40 mg by Mouth Every 6 Hours
18. Polyethylene glycol 17 gram PO Twice Daily.
19. Methylnaltrexone (RELISTOR) 8 mg/0.4 mL every 7
days
20. Bisacodyl 10 mg suppository daily PRN
21. Amlodipine 5 mg PO Once a Day
22. Simvastatin 20 mg PO once a Day
23. Trimethoprim 100 mg PO daily
24. Cranberry extract 1 Cap by Mouth Twice Daily

Medications (cont.)
25. Gentamycin Urinary Irrigation TID
26. Acetaminophen 650mg 4 Times Daily
27. Lidocaine (LIDODERM) 5 %(700 mg/patch)
28. Diclofenac sodium 1 % TP GEL to the knees
29. Budesonide 0.5 mg/2 mL BID
30. Benzonatate 100 mg TID as Needed
31. Albuterol 2.5 mg/0.5 ml BID
32. Ipratropium 0.02 % Every 4 Hours PRN

Medications (cont.)
33. Therapeutic multivitamin-minerals Once a Day
34. Cholecalciferol 1000 unit PO TABS 2 Tabs a day
35. Zinc ox-aloe vera-vitamin E 11.3 % TP CREA1
Application to affected area BID
36. Ascorbic acid 500 mg Once a Day
37. Zinc sulfate 220 mg into tube Once a Day
38. Nystatin 100,000 unit/g to affected area Twice Daily
39. Aquaphor TP oint 1 Application to affected area
Twice Daily
40. Cetaphil cleanser 1 Application to affected area
Once a Day

Physical Exam
Vital signs: BP: 117/58 Temp: 98.5 ⁰ F (36.9 ⁰ C) RR:
18/min HR: 89 b/min
183 lbs; Height: 72 inch ( 193 cm); BMI: 22.28
Patient chronically ill looking; minimally verbal; says
his name. Difficult to understand
Has masked face. He does say "hello" at the
beginning but has little spontaneous speech
otherwise.
HEENT: PERRL. EOM are slowed. Visual fields are
intact. Has dry oral mucosa.

Physical Exam-contd
Lungs; Clear to auscultation
Heart: S1, S2, regular/regular no murmur
Abdomen; mildly distended, normoactive
bowel sounds; has PEG tube in left upper
abdomen, presence of suprapubic catheter in
lower abdomen
Extremities; Trace bilateral leg edema; distal
pulses symmetric 1+

Physical Exam (cont.)
+ Cogwheel rigidity in bilateral upper extremities.
No resting tremor was noted
Neuro/Psych exam: Affect is blunted. Unable to
judge attention and concentration, calculation or
memory appropriately due to patient status. He
does follow commands during exam, however,
though very slowly. Language and Speech are
impaired with a paucity of verbal response and
hypophonic speech. There is no facial asymmetry
17

Physical Exam (cont.)
There is no focal weakness noted on gross
testing of extremities
Skin: Presence of an open area 0.3 cm
surrounded by blanchable erythema in
sacral area
18

Functional Status
Functional status: Dependent in all ADL’s,
needs two person assist to transfer from bed
to wheelchair

Chart Review 2009/2010
In 2009 admitted with Lithium Toxicity. Noted to
have Parkinsonism at that admission, neurology
recommended Carbidopa-Levodopa
2010
June; ED visit; multiple complaints which mostly
are chronic; patient and daughter requested X-ray
of back
July; ED visit; Chronic Neck and Back pain; minor
MVA few days prior. No history re MVA
August; ED visit; neck pain; MVA 3 days prior

2012
January: ED visit Urinary retention; Foley Catheter
placed; Follow up with PCP and Urologist advised.
Patient followed up with his PCP in VA and failed
voiding trial.
May: Brought to ED via EMS, found down on a
Boulevard close to his home. Diagnosed and
treated for UTI and Sepsis. Extensive work up for
delirium. EEG/ Head MRI/ Head CT:
unremarkable. He was transferred to Gero-psych
unit for auditory hallucinations. He was
discharged to a SNF. Follow up with urology at VA
was advised and appointment was made.

2012
ED visit June: Patient presented to ED from a SNF
with multiple complaints. ED physician calls
Community Service Board to evaluate patient.
However his daughter takes him back to the SNF
facility.
July: Admit for delirium; neuro consult. LP and
extensive work up. All negative. Palliative consult:
patient chose to be DNR/DNI
July admitted to urology for hematuria. Resolved
with irrigation.

2012
August: Hypotensive, septic shock,
admitted to ICU; intubated for resp.
failure. Extubated after few days.
Developed abd. pain and had exploratory
LAP
August : Transferred to medicine from ICU
August/Sep:Transferred to Gero-psych
unit for acute psychosis, hallucinations

2012
September : Transferred back to medicine
from Gero-psych; Patient with poor PO
intake. Ethics and palliative care were
consulted; NO PEG TUBE was advised. It is
clearly mentioned in his AD that he does
not wish to have PEG tube, but daughter
was insisting that her father needs PEG
tube. He did not get PEG tube. He was
discharged to SNF.

2012
September/Oct: Admitted from SNF for
hypernatremia; thought to be secondary to
poor po intake. PEG tube placed
October: readmitted from SNF with
Hematuria
Nov/Dec: patient had 2-3 hospital admits
to another hospital system in the area; No
records available ;had suprapubic catheter
placed during one of these admits.

2013
January Hospital admit, pus around the
suprapubic catheter; He was discharged to
our SNF
February hospital admit with abdominal
pain and ileus; EGD and colonoscopy
performed; transferred back to our SNF
upon discharge

27
Thank You!