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Geriatric Combined Conference

指導：蒲秀瑾醫師 報告： PGY 江泓賢 報告日期： 2012/8/29. Geriatric Combined Conference. General Information. Gender: male Age: 79 y/o Marriage: widower Race: Taiwanese Occupation: grocery store, retired Education: junior high school 資料來源 : children and care-giver Date of admission: 2012/8/8.

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Geriatric Combined Conference

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  1. 指導：蒲秀瑾醫師 報告：PGY 江泓賢 報告日期：2012/8/29 Geriatric Combined Conference

  2. General Information • Gender: male • Age: 79 y/o • Marriage:widower • Race: Taiwanese • Occupation: grocery store, retired • Education: junior high school • 資料來源: children and care-giver • Date of admission: 2012/8/8

  3. Chief complaint • Gross hematuria for 2 days

  4. Present Illness (1) • Hematuria was noted for 2 days. • With nocturia • No dysuria, no urgency, no frequency, no intermittency • No fever or chills. No headache/dizziness. No chest pain/tightness. No abdominal pain. No flank pain. No trauma history. No contact or traveling history. • Fighting behavior and irritable

  5. Present Illness (2) • He was sent to ER on 8/6. Urinary tract infection was impressed. Urologist was consulted and patient was inserted Foley cath.. • Then he was admitted on 8/8 for further management. • Trace back to his history… • BPH, s/p TURP in 2010/10  • Bladder tumor found for 2 years about 1.7cm over lateral wall, Operation on 20101028: stone(+), left hemitrigone area swelling and erythematous change, no typical TCC looking

  6. Patient’s other underlying problems • Hypertension • Type 2 diabetes mellitus, diet control • Bipolar disorder in 2003 (出現攻擊行為,躁動不安,自言自語,有時則情緒低落) and follow-up at 桃療 regularly since 2008(因攻擊鄰居並毀壞門窗強制接受治療) • Dementia with behavioral and psychological symptoms

  7. Patient’s other underlying problems • HCV related hepatitis with cirrhosis • Thrombocytopenia, favor cirrhosis related • Multiple small sized colon polyps and gastric ulcer history reported by the health exam in 2003

  8. Personal History • Allergy: no known allergy to food or drug • Cigarette smoking: 1-2 PPD for more than 40 years • Alcohol drinking: denied • Betelnut chewing: denied

  9. Family history • No hypertension • No DM • No psychosis

  10. Review of system (1) • 1.General: weakness: (yes), fever: (no) • 2.Skin: wound: ( no) • 3.HEENT: Head: headache: (no ),Ear: hearing impairment: (yes) • 4. Respiratory: cough: (no), dyspnea: (no) • 5. CV: chest pain : (no)

  11. Review of system (2) • 6. GI: vomiting: (no), abdominal pain: (no) • 7. GU: **On Foley hematuria: (gross hematuria) • 8. Metabolic and endocrine: Polyphagia (no) • 9. Hematological: anemia: ( no ) • 10. Neuropsychiatry : dizziness ( no) • 11. musculoskeletal: muscular weakness( yes)

  12. Physical Examination (1) • BT:36.3C, PR:66/min, RR:18/min, BP:143/65 mmHg, BH:170 cm, BW:60 Kg, BMI:21 • E4V3M6 • Consciousness: clear • Not anemic, not icteric • Neck: supple, no LAP, no carotid bruit • Chest: clear BS • Heart:RHB, no murmur

  13. Physical Examination (2) • Abdomen: soft, nopalpable mass, no tenderness/rebound pain. Bowel sound normoactive • Back: no tenderness, no flank knocking pain • Extremities: symmetric pulsation, no edema, ROM full • Neurological examination: no focal deficit

  14. CBC on 8/6 (ER)

  15. Urinalysis on 8/6 (ER)

  16. Biochemistry on 8/6 (ER)

  17. Impression on admission at 8/8 • Hematuria, cause? suspect bladder tumor related • Urinary tract infection • Prostate benign hyperplasia , s/p TURP in 2010/10 • Hypertension • Diabetes mellitus • Bipolar disorder • Dementia • Hepatitis C with liver cirrhosis and thrombocytopenia

  18. Treatment plan on admission • Diagnostic: • Follow U/A, U/C, Hemogram and Biochem. Data • Arrange non invasive exam first such as kidney echo and TRUS • Consult urologist for possible cystoscope • Arrange CXR, KUB to rule out other possible infection focus • Theraputic: • Transamine use • Empiric antibiotics • Consult psychiatrist for adjustment the medication prescribed by 桃療

  19. Hospital course… • After admission, psychiatrist was consulted and keep antipsychotic medication from 桃療 was suggested. • Medication: • Trihexyphenidyl 2mg 1PC QD • Piracetam 1200mg 1PC BID • Estalozam 2mg 1PC HS • Trazodone 50mg 1PC HS • Lithium carbonate 300mg 1PC HS • Olanzapine 10mg 1PC HS • Valporate 200mg/ml 1ML Q8H

  20. ChestX ray(8/9) • Old fracture of left clavicle and left ribs • The heart size and shape within normal limits • Mild infiltration on BLL

  21. KUB (8/9) • Degenerative change with bony spur formation of L spine • Scoliosis of the L spine • Increased bowel gas • Clear bilateral psoas muscle shadow

  22. EKG on 8/9 • Normal sinus rhythm • Left axis deviation

  23. Renal echo 8/13

  24. TRUS 8/13 • bladder: incompletely distended without abnormal seen • seminal vesicle: symmetric with clear content • On Foley catheter. • Prostate: Marked enlarged, 4.98 x 4.23 x 5.34 cm, size about: 58.49 gm ,T zone: 42.46 gm

  25. Rehabilitation Consultation on 8/14 • 因病人躁動不安且無法配合,應先控制急性期症狀,目前實行復健並不合適

  26. Colonscope and PES on 8/16 • Colonfibroscope: • Incomplete study due to much of stool • Panendoscope: • Tiny gastric ulcers

  27. Cystoscope on 8/16 • Incomplete sutdy due to turbid urine, blood clot and patient’s poor compliance • Urologist suggest further survey under general anesthesia, but patient’s famiy refused due to the high risk

  28. Fever episode on 8/16 night • Turbid urine and gross hematuria with blood clot, progressing • Change antibiotics to levofloxacin (Urine culture revealed Pseudomonas) • BT with PLT 12U due to progress thrombocytopenia

  29. Chest X ray and KUB (8/17)

  30. Problem lists • Medical • Psychological • Physical • Nutrition • Social-economic

  31. Medical problems • Hematuria, cause? • DDx: bladder tumor, UTI, urolithiasis, prostatitis, GNs, thrombocytopenia…… • Urinary tract infection • Prostate benign hyperplasia , s/p TURP in 2010/10 • Hypertension • Diabetes mellitus • Bipolar disorder • Dementia • Hepatitis C with liver cirrhosis

  32. Cognition • Education: 初中 • MMSE:無法評估

  33. Geriatric depression scale • GDS:無法評估

  34. Sensory deprivation • Hearing impairment (yes, bilateral) • Visual impairment (no) • Body sensation (preserved)

  35. ADL Barthel index : 0/100 Total dependent Foreign caregiver

  36. Iatrogenesis • Polypharmacy ( yes) • Tubes (Foley catheter) • Foley catheter (yes) • NG tube ( no) • Tracheostomy( no) • Pressure ulcer (no)

  37. Psychological problem • Delirium (?) • Depression (yes) • Dementia (yes)

  38. Physical • ADL: total dependent • Swallowing: normal

  39. Nutrition • BH：170 cm, BW：60 kg, BMI: 21 • Albumin: 3.34 gm/dL • Hemoglobin:12.2 gm/dL • Lymphocytes: 1280/mm3 • Recent body weight loss (no) • Mininutritional assessment, short form:6/14 , 11/30, malnutriton

  40. Social economic status • Main caregiver: foreign aid and sons (病人輪流住在大兒子和二兒子家)

  41. Ethic discussion • Family support: good, but… • 家屬對病患的處置有兩派看法 • (積極控制vs消極處理) • Economic condition: no problem

  42. Geriatric combined conference • Physician • Nurse • Physical therapist • Occupation therapist • Nutritionist • Pharmacist • Social worker

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