Case 1 - POGOe



Case 1: I’VE FALLEN AND I CAN’T GET UP

Chief complaint

An 84-year-old man was found by his daughter on the floor of his apartment after failing to answer the telephone for a day. He complained of pain in his left knee, but was otherwise confused and unable to explain what had occurred. He was brought to the hospital by ambulance and admitted.

Questions:

1. Which of the following is an incorrect statement about falls in the elderly?

a. Falls in the elderly are often due to a combination of intrinsic and extrinsic factors medications

b. Older adults should be asked at least once yearly about falls.

c. The incidence of falls decreases with age due to an overall decrease in mobility

d. Risk factors for falls include all of the following: a prior history of falls, cognitive impairment, psychotropic drugs, anemia, and lower extremity weakness.

e. b and d

Past Medical/Surgical History – provided by the daughter

Myocardial infarction ten years ago

Hypertension

Peptic ulcer disease with bleeding 20 years ago

Benign prostatic hypertrophy

Venous insufficiency

Bilateral cataract surgery 5 years ago

Left inguinal hernia repair 25 years ago

Medications:

aspirin 325 mg daily atenolol 50 mg daily one Multivitamin daily

Vitamin E 800 U daily terazosin 5 mg daily lisinopril 10 mg daily

Vitamin C 1000 mg daily Ginkgo biloba one capsule daily

Questions:

2. Which medication(s) most likely contributed to the fall risk in this patient?

a. atenolol

b. terazosin

c. lisinopril

d. a and b

e. all of the above

f. none of the above

Social History – provided by the daughter

He lives alone and is able to care for himself. A woman cleans his apartment twice weekly and also does some shopping. His daughter is very involved and calls about every third day. He was a bookkeeper, retired at age 65 and became a widower at age 70. He manages his own finances and enjoys baseball on TV. He denies any recent change in appetite, has some rolls and coffee for breakfast, lunch at the senior center, and for dinner, he usually warms something left by his cleaning lady or eats at a restaurant near his home. He smoked 2 packs a day from age 20 to age 55 when he stopped after an episode of pneumonia. He rarely drinks more than one drink an evening. He does not exercise, and takes his medications as prescribed.

Physical Examination:

In the emergency room, his physical examination revealed a thin male who appeared alert but agitated and in moderate pain, lying on the stretcher.

His vital signs were:

Pulse 48 Weight 140 lbs

Blood pressure lying down 190/70 Height 5 ft. 9 in.

Respiratory rate 20 Temperature 99( F

Questions:

3. Why is the systolic blood pressure elevated?

a. This patient has essential hypertension and has not taken his medication

b. Systolic hypertension is expected with normal aging

c. This patient is anxious and in pain

d. All of the above

e. a and c are correct

f. b and c are correct

Questions:

4. Why may his heart rate be slow?

a. Normal heart rate declines with age

b. the atenolol slows the heart rate

c. he may have sinus node disease

d. all of the above

e. a and c are correct

f. b and c are correct

Physical Examinaton, continued:

Skin examination: Two large areas (10cm diameter) of ecchymoses (red to purple) on left thigh and left side of back and multiple small tan, scaly, waxy, raised lesions that appear pasted on or “stuck on” (3-5 cm diameter) located on his chest and back.

Questions:

5. The large ecchymoses look acute and are attributed to the fall. The ecchymoses on the arms appear older. The physician is concerned that there might be a bleeding tendency. The patient takes ginkgo, vitamins C and E, in addition to her other medications. Which of the agents listed below could contribute to the bruising? More than one answer can apply.

a. ginkgo biloba

b. vitamin C

c. vitamin E

d. atenolol

e. aspirin

f. all of the above

Questions:

6. This skin lesions on his chest and back are likely to be:

a. basal cell carcinoma

b. squamous cell carcinoma

c. actinic keratosis

d. malignant melanoma

e seborrheac keratosis

f healing ecchymosis

Physical Examination, continued:

Only pertinent negative or positive findings as reported

Head, ears, eyes, nose and throat: slight ptosis on right, bilateral lens implants, discs not well visualized

Neck: no jugular venous distension or bruits. Thyroid not palpable. No lymphadenopathy

Chest: symmetrical excursions, scattered ronchi, particularly at the left base

Heart: PMI (point of maximal impulse) slightly displaced laterally, normal S1, S2, +S3, regular rate and rhythm, no murmurs, rubs

Abdomen: soft, no masses palpable.

Rectal: slightly decreased tone, large amount of firm brown stool, guaiac negative, prostate symmetrical and enlarged, firm but not hard

Extremities: left lower extremity externally rotated and shorter, 2+ edema bilaterally, brawny discoloration of ankles and lower legs to midcalf.

Pulses: dorsalis pedis 1+ bilaterally

Impression and Plan:

Based upon this examination, the patient is admitted for a presumed hip fracture. Radiographs, laboratory testing and an EKG is ordered.

Questions:

7. What findings suggest that the patient has a hip fracture?

a. knee pain

b. left leg externally rotated

c. left leg shortening

d. all of the above

e. a and c

f. b and c

g. none of the above

Hip Radiograph:

Interpretation: right proximal femur fracture, osteopenia

Questions:

8. Is the fall sufficient to cause a hip fracture, or should a “pathologic fracture” ie. due to metastatic disease or infection in the bone, be considered in this patient?

a. If the medical evaluation is negative (history, physical and routine laboratory testing), the fall is sufficient to have caused a fracture in a patient with osteopenia. No further evaluation is needed

b. An MRI of the hip is needed prior to surgery to rule out another cause of fracture in an elderly person.

c. A biopsy at surgery should be done to rule out malignancy or infection

d. A bone scan should be done prior to surgery to identify an areas of other bone disease and rule out another cause of fracture

e. All of the above

f. None of the above

Physical Examinaton, continued:

Neurologic examination: alert, agitated, moving around stretcher. Able to provide name, uncertain about location and date, unable to retell events leading up to admission. Somewhat uncooperative with commands. Poor hearing. Can provide name of daughter but not telephone number. Cranial nerves intact except for ptosis on the right and poor hearing. Slightly decreased sensation in lower extremities. Reflexes 1+ in right knee and elbows. Too much pain in left side to examine. Normal tone. No tremor.

Hospital Course:

Surgery (ORIF-open reduction and internal fixation) is contemplated for the next day. During the pre-operative assessment, the patient becomes combative when his left leg is moved. He is still confused about today’s date and the sequence of events leading up to his hospitalization, but appears to understand when he is told that his hip is broken and that an operation to fix it is recommended. When the resident tells him he will not be able to walk again without surgery, he yells “NO SURGERY!” and refuses to speak or listen further.

Although the surgery is not an emergency, patient outcomes are better if it is undertaken as soon after the fracture as possible. The attending has arranged time on the Operating Room schedule for the next day. The resident leaves the bedside to call the patient’s daughter.

Questions:

9. Requirements for informed consent to or refusal of treatment include:

• Decisional capacity (the ability to understand one’s medical situation, weight the benefits, burdens and risks of treatment options, apply personal values, make a decision that is consistent over time, and communicate the decision)

• Disclosure by care providers of sufficient information relevant to the decision

• Understanding of the information disclosed

• Voluntariness in acting without coercion or compulsion

In this circumstance, which of the criteria are lacking:

a. decisional capacity

b. full disclosure

c. understanding

d. voluntariness

e. all of the above

f. A, B and C

g. A and C

h. None of the above are lacking

Hospital Course:

The resident calls the daughter who is very concerned. The resident explains that the surgery involves general anesthesia and the placement of a pin in the hip. Common complications include bleeding which may require blood transfusion and infection. The benefits include pain relief and regaining of the ability to walk following rehabilitation. The daughter says that “surgery sounds like the right thing to do; and it doesn’t sound like Dad to refuse. He is always cooperative and quiet, spends his time reading the New York Times and doing the crossword, and has had surgery before, so that he should know what it involves.”

Question:

10. This patient’s ability to provide informed consent is uncertain. Should the daughter provide consent so that surgery can be undertaken now?

a. Surgery should be done now without consent because of the seriousness of his condition

b. The daughter should be asked to provide consent, and if she agrees, surgery may be done now despite the patient’s refusal

c. Unless it is an emergency, surgery should be delayed and further discussions can occur at a later time.

d. Surgery cannot be done at any time because he has refused, and he should be sent to a nursing home for pain control and rehabilitation.

Admission laboratory data:

Complete Blood Count: hemoglobin 12.3 (14-18) g/dl hematocrit 34% (42-52%) White Blood Cell count 7.8 (4.8-10.8) kuL

Chem: Na 147 (135-145) mEq/L

K 3.8 (3.5-5.0) mEq/L

CO2 25 (24-30) mEq/L

Cl 105 (98-108) mEq/L

Gluc 200 mg/dl

BUN 41 (10-26) mg/dl

Creat 1.8 (0.5-1.5) mg/dl

Question:

11. The elevation in glucose in this patient at this time is most likely due to:

a. Metabolic changes of aging causing hyperglycemia

b. diabetes mellitus type II

c. stress

d. all of the above

e. a and c are correct

f. b and c are correct

Hospital Course:

The patient is given acetaminophen and oxycodone for pain every four hours as needed, diphenhydramine for sleep and well as intravenous hydration. All previous medications are discontinued. A foley catheter is placed and the leg put in traction. The nurse calls the resident at 10 pm to return after he was uncooperative with using a bedpan and intentionally pulled out his intravenous line (IV). When the resident returns to the bedside at 11, he finds the patient lethargic and replaces the IV.

Question:

12. This patient’s agitation is due to:

a. dementia

b. delirium

c. depression

d. all of the above

e. A and B are correct

f. A and C are correct

g. None of the above

Question:

13. What may be contributing to this patient’s agitation?

a. dehydration

b. oxycodone

c. diphenhydramine

d. all of the above

e. a and c

f. none of the above

Hospital course:

In the morning the resident returns and the patient is coherent and cooperative. The resident explains the reasons for surgery and the risks. The patient agrees, and that afternoon undergoes open reduction and internal fixation of the hip. After surgery, pain medication, low molecular weight heparin and slow mobilization occur. The foley catheter is discontinued. Two days later, the patient is noted to have a fever of 101.8 and is confused and unable to urinate. Physical examination reveals a respiratory rate 12, BP 140/70, HR 72 and regular, clear chest, dependent edema, and hard stool in the rectum. The surgical wound is clean but an ulcer, 3 cm in diameter, is present to a depth through the skin but not down to bone or muscle is present on the sacrum. The base is pale white with surrounding erythema and yellow-red discharge.

Questions

14. Which of the following are likely causes of fever in this patient ?

a. urinary tract infection

b. pressure ulcer

c. deep venous thrombosis

d. pneumonia

e. all of the above

f. a, b, and c

g. a and c

h. none of the above

Question:

15. What stage is the ulcer by the the National Pressure Ulcer Advisory Panel classification?

a. stage I

b. stage II

c. stage III

d. stage IV

Question:

16. Should the discharge be cultured before starting antibiotics?

a. yes

b. no

Hospital Course:

The urinary tract infection is treated with oral antibiotics. Local wound care is done for the pressure ulcer. Physical therapy is begun and the patient begins to walk with a walker, but cannot manage to get up on his own or go to the bathroom. The social worker recommends that he go to a short term rehabilitation program in a local nursing home which would be paid for by his Medicare benefit. He refuses, stating he wants to get back to his apartment and doesn’t want a stranger there. The social worker explains that Medicare will cover home care services including physical therapy several times a week and an aide for a few hours a day, but that it is not safe for him to go home in this state without help. He says he understands that he cannot get around well yet and would get more therapy in the rehab facility, but he is sick of “being institutionalized and misses his privacy.” He will allow a physical therapist to come refuses to spend money on hiring extra help and will not allow the nurse or the aide to come “and bother him.”

Questions:

17. What discharge plan can be made?

a. He should be sent to the rehabilitation facility for a short stay over his objections

b. He should be sent home with the home care physical therapy, and information about the other services provided through home care and how to hire help

c. He should be kept in the hospital until he can get to the bathroom safely

d. His daughter should be told to stay with him as he won’t allow a stranger

e. His daughter should be told to employ extra help for him and pay for it since he won’t

Hospital Course:

The patient is discharged home with home care. His daughter volunteer to stay over night with him and he agrees. A bedside commode is ordered, along with grab bars for the bathroom. An office visit is planned for ten days later, and his daughter plans to continue telephone contact. His ability to transfer and ambulate improves quickly, and he is able to move about the home with a walker and quad cane after two weeks.

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