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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 l.jpg

May 2003 Geriatric Presentation

Toby Andrew Hampton, M.D.


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Patient ID

  • 75 y.o. White male

  • Veteran admitted to VAMC Mountain Home Nursing Home on 5/12/2003


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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.


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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


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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


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PMH Continued

  • Sensorineural Hearing Loss

  • Shy-Drager Syndrome

  • Benign Prostate Hypertrophy

  • Chronic Constipation

  • Parkinson’s Disease


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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.


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Current Meds on Admission

  • Aspirin

  • Tylenol

  • Sinemet

  • Fluocinolone

  • Latanoprost

  • Daily Multivitamin

  • PRN Nitroglycerin SL


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Meds Continued

  • Nitroglycerin patch

  • Pramipexole

  • Seroquel

  • Ranitidine

  • Simvastatin

  • Sorbitol and Mag Citrate prn

  • Allergic to Pcn and IVP dye


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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


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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


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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


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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


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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.


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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


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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.


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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.


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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.


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Shy-Drager Syndrome

AKA:”Multiple System Atrophy”


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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.


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Autonomic Dysfunction Symptoms

  • Urinary retention, incontinence

  • erectile dysfunction

  • orthostatic hypotension

  • apnea, or inspiratory stridor

  • snoring or loud respiration

  • Inability to sweat

  • Resistance to levodopa


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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.


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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


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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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