Case

Alma Pierce is an 80 year old female.  She is brought in by her daughter-in-law Phyllis who is concerned.  She has always been self-sufficient since her husband died 15 years ago.  Phyllis has noticed a gradual decline in her function over the last few weeks.  She has become more forgetful, somewhat lethargic, easily confused, has a poor appetite, and is unsteady on her feet.  Phyllis emphasizes that this is not like her at all.  She hopes that you can figure out what is wrong.  Ms. Pierce has a sixth grade education.

 Past Medical History:

1. Mild systolic heart failure (40% EF on echo last year)
2. Mild aortic stenosis (seen on last year’s echo)
3. Chronic renal insufficiency (recent BUN/Cr= 31/1.6)
4. Osteoporosis
5. Anxiety

Medications:  (There have been no recent medication changes)

1. Lasix 20 mg BID
2. KCl 20 mEQ daily
3. Digoxin 0.25 mg daily
4. Fosamax 70 mg weekly
5. Lisinopril 20 mg daily
6. Valium 5mg BID
7. Aspirin 81 mg daily

Social history:  Ms. Pierce lives in her own first-floor apartment and her daughter-in-law Phyllis lives upstairs and checks in on her a few times a day.  She does not use alcohol, tobacco or drugs.  She is not sexually active.  She has been your patient for 20 years and you know her very well.  Alma’s husband died 15 years ago.  This was difficult for her at the time, but she was able to grieve appropriately with family support.  She has a few friends who live nearby with whom she occasionally plays cards; otherwise she mostly stays at home.  She loves to do crossword puzzles.

ADL’s/IADL’s:  At baseline, Ms. Pierce is able to do all of her ADL’s independently (hygiene, continence, dressing, eating, toileting, and transferring).   Phyllis helps with several of her IADL’s including driving, food shopping, finances, some meal preparation, and putting her medications into a weekly pill box.  She has someone clean her apartment once a week.  Alma is able to do some light cleaning and cooking on her own.  Phyllis thinks that even in the last few weeks she has been taking all of her medications appropriately (they are gone from the pill box by the end of the week).

ROS:  Ms. Pierce states she feels fine. She wonders what all the fuss is about! No headaches, blurry vision, falls (that Alma admits to, and Phyllis states that she has not witnessed any), no fever or chills, no belly pain, dysuria, emesis, diarrhea, constipation or blood in stool.  No muscle aches or pains, no chest pain, no SOB. Occasional nausea.   Phyllis states that she has been more tired then usual lately and is taking more naps.  Phyllis thinks her appetite is decreased in the last week or so. She also says that she is forgetting things she does not usually forget; for example Phyllis tells her mother-in-law she will be coming down in an hour, and then Alma is surprised to see her.  She is ambulating without difficulty, but seems a little less steady on her feet.

Physical Exam:

 

Weight: 132 lbs (4 months ago was 133lbs)   Height- 5’3”  BP- 118/68   Pulse = 49 (baseline pulse in the 70’s)   RR= 16    Temp= 98

Orthostatics: Lying: BP 118/68, pulse 49  à Standing:  BP 102/66, pulse 53

Alert and oriented to name only, no acute distress, conversant.

 

HEENT: WNL except mucus membranes somewhat dry

CV: no carotid bruits, no JVD, S1S2 heard, RRR, 3/6 SEM (no change from previous exam), mild bradycardia, no peripheral edema b/l

 

Chest: CTA b/l no w/r/r

 

Abd: +BS soft NTND. No HSM, no rebound or guarding.

 

MMSE: 20/30

 

PHQ-9 =   4

 

Confusion Assessment Method :

Acute onset and fluctuating course : From your discussion with Ms. Pierce and Phyllis, there is evidence of change in cognition from baseline, and per Phyllis, this fluctuates during the day.

Inattention: Not able to count back from 20 to 1, not able to recite the days of the week or the months of the year

Disorganized Thinking: answers questions with difficulty, sometimes rambling or talking about things irrelevant to the conversation.

Altered level of consciousness: Appropriate

Labs/Studies

 

Na- 136, K-4.9, Cl- 99, CO2- 29, BUN-62, Cr- 2.4, glucose- 111

WBC- 8, Hb- 12, Plt- 200

TSH- pending

UA- negative

Dig level: 3.9

Cr clearance- 28

EKG:

 https://tuftsmedicine.pressbooks.pub/fmclerkshipmmc/geriatrics-ekg/

Team Based Learning Geriatric Case Questions

 

REVIEW HISTORY AND ROS

1. What are the three most important components of the physical exam for Ms. Pierce?REVIEW PHYSICAL EXAM
3. What are the three most important labs or students to order for Ms. Pierce?REVIEW LAB AND STUDIES
5. What is the most likely sequence of events, leading to Ms. Pierce’s presentation?
   1. dehydration from decreased appetite
   2. nausea an decreased appetite
   3. increasing age along with multiple medications
   4. digoxin toxicity
   5. acute on chronic renal failureREVIEW MANAGEMENT
6. Admit to hospital?
   1. Yes
   2. No
7. Assign to telemetry bed?
   1. Yes
   2. No
8. Start IV fluids?
   1. Yes
   2. No
9. Hold Digoxin?
   1. Yes
   2. No
10. Hold Lisinopril?
    1. Yes
    2. No
11. Hold Lasix?
    1. Yes
    2. No
12. Hold Potassium?
    1. Yes
    2. No
13. Hold Valium?
    1. Yes
    2. No
14. Hold Aspirin?
    1. Yes
    2. No
15. Consult Cardiology?
    1. Yes
    2. No
16. Start Digibind?
    1. Yes
    2. No
17. Consult Nephrology for dialysis?
    1. Yes
    2. No