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May 2003 Geriatric Presentation

May 2003 Geriatric Presentation. Toby Andrew Hampton, M.D. Patient ID. 75 y.o. White male Veteran admitted to VAMC Mountain Home Nursing Home on 5/12/2003. Chief Complaint and HPI. CC: Weakness, Falls, Hallucinations

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May 2003 Geriatric Presentation

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  1. May 2003 Geriatric Presentation Toby Andrew Hampton, M.D.

  2. Patient ID • 75 y.o. White male • Veteran admitted to VAMC Mountain Home Nursing Home on 5/12/2003

  3. Chief Complaint and HPI • CC: Weakness, Falls, Hallucinations • Pt. Has Parkinson’s disease and has had hallucinations since starting Sinemet. Recent addition of Seroquel has not alleviated hallucinations. • Pt. Also c/o recent increase in weakness and falls about 1X q day.

  4. HPI Continued • Pt. Had been living at home with his wife but due to the increase in weakness and falls, the wife is no longer able to care for him. • He is admitted to NH here for med adjustment and for PT to increase strength and endurance. • Dizziness worse with Seroquel

  5. PMH • Coronary artery bypass times 4 on 5/30/1996 • Peptic Ulcer Disease • Ocular histoplasmosis dx in 1980, legally blind • Degenerative joint disease, Arthritis • HTN • Hyperlipidemia • Phlebitis of superficial vessels in lower extremity

  6. PMH Continued • Sensorineural Hearing Loss • Shy-Drager Syndrome • Benign Prostate Hypertrophy • Chronic Constipation • Parkinson’s Disease

  7. Other Hx: • Social hx: Lives at home with wife until admission, No alcohol, No tobacco for the past 20 years, No illegal drugs. Has 3 children • Fam. Hx: Pt. Can’t recall any illnesses is the family.

  8. Current Meds on Admission • Aspirin • Tylenol • Sinemet • Fluocinolone • Latanoprost • Daily Multivitamin • PRN Nitroglycerin SL

  9. Meds Continued • Nitroglycerin patch • Pramipexole • Seroquel • Ranitidine • Simvastatin • Sorbitol and Mag Citrate prn • Allergic to Pcn and IVP dye

  10. Review of Systems • 20 lb weight loss over past 6 months • Dry eyes • Cough each am with brown sputum • Constipation • Some night-time incontinence • Arthritic pain in hands, knees, and hips • + Hallucinations, No depression

  11. Physical exam • Vital signs • Wt. 181.7 lb • Temp: 95.3 • Pulse: L-70; SI-70; St-78 • Resp: 18 • BP: L-133/65; SI-119/70; St-94/55

  12. Physical Exam • General: alert, oriented to person and place, but not to time; resting tremor • HEENT: masked facies, missing two molars, TM’s occluded by cerumen • Neck: No thyromegaly, No carotid bruit • CV: RRR, no m,r,g; Chest- gynecomastia • Lungs: CTAB • Abd: Soft, +BS, NT, ND

  13. Physical Exam • Extremities: no c/c/e, UE muscle strength 5/5 bilat. And LE 4/5 stength bilat.; DTR’s UE and LE 1+ bilat. • Neuro- CN 3-12 intact. CN 2 affected by near blindness. Gait very unsteady. Monofilament exam reveals sensory deficit to ankles bilat. Proprioception of toes and foot is intact bilat. Skin-Mult. bruises

  14. Misc. • MMSE- 26/30 • Geriatric Depression Scale 2/30 • Pt. Does need assistance with his ADL’s and cannot perform any IADL’s • Pt.’s wife states hat their inances are holding OK for now.

  15. Pertinent Lab DATA • 5/12/03: UA-WNL; INR 1.25; BMP-WNL; Total Chol-140; WBC 7.3; HGB 14.7; HCT 42.5; PLT 188 • 4/23/03: NH3 <0.9, FOLATE 317; RPR-nonreactive; TSH-2.2; VIT B12-749

  16. Nursing Home Course • Pt. Tolerating PT quite well. • Seroquel discontinued. • Geodon 20 mg po bid started with a decrease in hallucinations per pt. • Pt. Still suffering from night-time incontinence. • Falls decreased to 1 q 2-3 days.

  17. Assessment and Plan • 1. Parkinson’s (Possible Shy Drager)- Cont. Sinemet and pramipexole. • 2. Hallucinations- Cont. Geodon and Geropsych is following. • 3. Weakness- Cont. PT • 4. Orthostatic Hypotension- monitor fluid intake and advise pt. To hold on to something as he stands up slowly to decrease orthostasis.

  18. Assessment and Plan • 5. Night-time incontinence- restrict fluids after 8 pm • 6. Constipation- Cont. prn sorbitol and Mag Citrate • 7. Falls- Likely multifactorial including Parkinson’s, orthostatic hypotension, poor sensation in feet, weakness, and blindness.

  19. Shy-Drager Syndrome AKA:”Multiple System Atrophy”

  20. Facts about Shy-Drager • Prevalence of 4.4 per 100,000 • 10% as common as Parkinson’s Disease • Avg. age of onset 54 • Predominately Male>Female • 75% of patients with diagnosis present with complaints related to autonomic dysfunction.

  21. Autonomic Dysfunction Symptoms • Urinary retention, incontinence • erectile dysfunction • orthostatic hypotension • apnea, or inspiratory stridor • snoring or loud respiration • Inability to sweat • Resistance to levodopa

  22. Movement Presentation • 25 % of patients with Shy-Drager Syndrome will present with movement symptoms related to cerebellar or striatonigral lesions. • These patients show the typical autonomic symptoms within 5 years of the movement symptons. • Movement symptoms of Shy-Drager are very similar as for Parkinson’s.

  23. Treatment • Dietary increases of salt and fluid • L-Dopa may be useful in some cases • sympathomimetic amines • NSAIDS • salt-retaining steroids • alpha-adrenergic meds • Sleeping in a head up position reduces am orthostatic hypotension

  24. Prognosis • Progressively fatal disease • Death usually occurs within 7-10 years of diagnosis • Death usually ensues secondary to stridor, aspiration pneumonia, or cardiac arrest.

  25. The End

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