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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

May 2003 Geriatric Presentation

Toby Andrew Hampton, M.D.

patient id
Patient ID
  • 75 y.o. White male
  • Veteran admitted to VAMC Mountain Home Nursing Home on 5/12/2003
chief complaint and hpi
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.
hpi continued
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
slide5
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
pmh continued
PMH Continued
  • Sensorineural Hearing Loss
  • Shy-Drager Syndrome
  • Benign Prostate Hypertrophy
  • Chronic Constipation
  • Parkinson’s Disease
other hx
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.
current meds on admission
Current Meds on Admission
  • Aspirin
  • Tylenol
  • Sinemet
  • Fluocinolone
  • Latanoprost
  • Daily Multivitamin
  • PRN Nitroglycerin SL
meds continued
Meds Continued
  • Nitroglycerin patch
  • Pramipexole
  • Seroquel
  • Ranitidine
  • Simvastatin
  • Sorbitol and Mag Citrate prn
  • Allergic to Pcn and IVP dye
review of systems
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
physical exam
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
physical exam12
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
physical exam13
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
slide14
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.
pertinent lab data
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
nursing home course
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.
assessment and plan
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.
assessment and plan18
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.
shy drager syndrome

Shy-Drager Syndrome

AKA:”Multiple System Atrophy”

facts about shy drager
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.
autonomic dysfunction symptoms
Autonomic Dysfunction Symptoms
  • Urinary retention, incontinence
  • erectile dysfunction
  • orthostatic hypotension
  • apnea, or inspiratory stridor
  • snoring or loud respiration
  • Inability to sweat
  • Resistance to levodopa
movement presentation
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.
treatment
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
prognosis
Prognosis
  • Progressively fatal disease
  • Death usually occurs within 7-10 years of diagnosis
  • Death usually ensues secondary to stridor, aspiration pneumonia, or cardiac arrest.
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