History
Identifying Data:
Full Name: TJ
Address: N/A
Date of Birth: N/A
Date & Time: 7/10/2023, 1:30pm
Location: St. Albans VA
Religion: N/A
Source of Information: Self
Reliability: Unreliable
Source of Referral: Self
Mode of Transport: N/A
Chief Complaint: Here for continuation of care
73 y/o male St. Alban’s resident, ADL/IADL dependent, wheelchair user, with h/o Parkinson’s disease (on carvidopa/levodopa), dementia, HTN, HLD, BPH, osteoarthritis, dysphagia, sciatic nerve paralysis, and chronic constipation, presented to Manhattan VA ED on 6/22 with pseudo-obstruction of colon secondary to Parkinson’s vs Parkinson meds. At St. Albans on 6/22 resident was observed to be unresponsive on the toilet after soft moderate amount of bowel movement with eyes opened, flaccid extremities, and unresponsive to verbal and tactile stimuli for approx 2mins. Plain x-ray showed colonic distension, at which time was transferred to ED (6/22) in the evening after vasovagal episode.
Upon arrival to Manhattan VA ED (6/22), patient’s vitals stable with HR in the 90s, BP was 120/83, SpO2 97% on room air. Labs showed WBC of 12.1, Hgb 16.3, Plt 263, BUN
28 Cr 1.3, Na 143, K 3.4, and LFTs within normal limits. X-ray was performed that showed evidence of large bowel distention and CT of abdomen and pelvis with rectosigmoid lesion concerning for malignancy, diffuse colonic distention up to 12cm in transverse colon, distension of small intestine which was also suggestive of incompetent recto-cecal valve. A nasogastric tube was placed in ED with ~300 cc bilious output and was then admitted to surgery for colonic NGT tube decompression.
Patient admitted to surgery 6/22 with decompression with NGT. GI was consulted for endoscopic placement of distal stent, but GI at VA was not capable of doing so and resident was transferred to NYU for further management with endoscopic decompression. Colonoscopy at NYU showed no evidence of obstruction, mass or stricture; therefore, distention suspected to be Ogilvie Syndrome secondary to Sinemet, so Sinemet was held on 6/23. On 6/24, patient had a bowel movement with a benign exam, and then transferred to medicine for further management.
Patient admitted to medicine on 6/24 with stable vital signs and GI consulted. Clamp trial of NG tube was begun to assess if able to be removed for administration of “by mouth” bowl regimen. Non-contrast head CT obtained 6/24 in the evening given change in baseline mental status; patient was no longer tracking or as alert per son. Non-contrast head CT was unremarkable. Abdominal XR also performed and was unchanged with dilated loops of bowel. Last bowel on 6/25 in the morning. Pt was observed to be gurgling requiring frequent suctioning q2hr. CXR was then obtained with findings consistent with new aspiration PNA. NGT removed and saline nebs and chest vest therapy were initiated. Resident was then up-triaged to MICU for frequent suctioning and further management.
Patient up triaged to MICU. In MICU, NGT replaced for medication administration and restarted on Sinemet as withdrawal from parkinson’s meds was more likely to worsen Ogilvie syndrome, esophageal motility, and altered mental status. Resident had ongoing bowel distention and concurrent profuse diarrhea requiring rectal tube placement, c diff negative. Treated with IV fluids and oral K for hypokalemia. Mental status also improved back on Sinemet and was requiring less frequent suctioning. Was also treated with 1mg of neostigmine on 6/28 and 6/29
with improvement in colonic distension on KUB, and significant improvement seen with neostigmine drip for 36 hours started 7/1. Trickle feeds were started on 6/29 which pt tolerated well and was weaned off after evaluation by SLP and was cleared for puree diet. Neuro was consulted for optimization of PD regimen. Pt had continued liquid BMS off of neostigmine via rectal tube with PO intake of about 30-50% of meals, no aspiration events. Serial improvement in abdominal exams and imaging. Pt was then moved to the medicine floor on 7/5.
On the medicine floor, rectal tube and NGT removed on 7/5 and started on puree diet.
Abdominal exam improved, continued to have BMs, and was considered stable for
discharge to St. Albans on 7/10.
Today (7/10) resident continues to be stable. Resident intermittently verbal, but speech incoherent at baseline (speaks 1-2 sentences, opens eyes to verbal stimuli and grimaces, nods or raises eyebrows at baseline). Denies abdominal pain, headache, constipation, N/V/D, chest pain, SOB, fever or chills.
Past Medical History:
Parkinson’s disease
Hyperlipidemia
Hypertension
Dementia
BPH
Osteoarthritis
Dysphagia
Sciatic nerve paralysis
Chronic constipation
Childhood Illnesses- N/A
Immunizations – Up to date; flu vaccine (9/9/22), COVID vaccine (12/12/22); shingles vaccine (1/28/22, 7/6/22); pneumonia vaccine ( 9/3/19);Tdap (5/27/22)
Screening test and results – Last colonoscopy 6/22/23, with no evidence of obstruction, mass or strictures
Past Surgical History:
No past surgical history.
Denies any blood transfusions
Medications:
Bacitracin 2% 1/32 oz packet topical ointment, apply small amount daily to abrasion on right shin, cover with mepilex dressing until healed.
Carbidopa 25/levodopa 250mg tab 2 tablets PO SU-MO-TU-WE-TH-FR-SA@0700-1500 put in applesauce
Enoxaparin NA (lovenox) injection 40mg/0.4ml SC daily
Melatonin cap/tab 3mg PO QHS crushed in applesauce
Multivitamins (adult) liquid,oral 5 ml PO daily
Petrolatum/mineral oil topical cream, apply liberal amount topically daily (7am) to bilateral legs to relieve dry skin.
Polyethylene glycol 3350 powder, oral 1 packet PO bid
Simvastatin (zocor) tab 10mg po QHS crushed in applesauce
Allergies:
NKDA
Family History:
Son: alive and well
Unable to obtain information on mother and father due to cognitive impairment.
Social History:
Mr. TJ is a retired corrections officer who served in the US Army during Vietnam era stateside. Prior to being a resident at St. Albans, lived with wife before caring for him became too demanding.
Habits – Per chart has history of smoking (pack year history unknown). Smoking included cigarettes. Per chart history of alcohol use and drugs.
Travel – No recent travel.
Diet – Resident on puree diet.
Exercise – Unable to exercise due to cognitive impairment and limited mobility.
Sexual Hx – N/A
Advanced directive discussed
Review of Systems: (limited due to cognitive impairment; responses based on grimacing and head nod and nursing notes)
General –Denies recent weight loss or gain, fever or chills, night sweats, loss of appetite, or generalized weakness/fatigue.
Skin, hair, nails –Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.
Head – Denies headache or head trauma.
Eyes – Denies lacrimation, pruritus, visual disturbances. Does not wear glasses. Does not recall when his last eye exam was or what his visual acuity or pressure is.
Ears – Hearing aids when needed. Denies deafness, pain, discharge, tinnitus.
Nose/sinuses – Denies discharge, epistaxis, or nasal polyps.
Neck – Denies localized swelling/lumps or stiffness/decreased range of motion
Breast – Denies lumps, nipple discharge, or pain.
Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes. Does not recall when last dental exam was.
Pulmonary system – Denies dyspnea on exertion, cough wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular system –Denies irregular heartbeat, chest pain, edema/swelling of ankles or feet, syncope or known heart murmur.
Gastrointestinal system – Admits to chronic constipation, dysphagia. Denies nausea, diarrhea and abdominal pain. Denies change in appetite, vomiting, pyrosis, unusual flatulence or eructations, jaundice, hemorrhoids.
Genitourinary system – Denies dysuria and blood in urine. Denies nocturia, urinary frequency, urgency, hesitancy, dribbling, oliguria, polyuria, incontinence, or flank pain.
Menstrual/Obstetrical – N/A
Musculoskeletal system – Denies muscle/joint pain from arthritis. Denies deformity or swelling, or redness.
Nervous – Denies weakness or loss of strength. Denies confusion, altered mental status, seizures, headache, ataxia, change in cognition.
Peripheral vascular system – Denies peripheral edema, intermittent claudication, coldness or trophic changes, varicose veins, or color changes.
Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT. Denies blood transfusion.
Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.
Psychiatric – Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.
Physical
General: Male appears clean, with eyes closed, observed in fetal position. Does not seem like a reliable source of information based on cognitive status. Does not appear to be in acute distress. Pt appears as stated age.
Vital Signs: BP: (R) laying down 102/64 P: 87 beats/min, regular
R: 18 breaths/min, unlabored O2 Sat: 98% on room air
T: 97.8 degrees F (oral)
Height: 67 inches Weight: 53.52 kg BMI: 18.4
Head, Skin, & Nails
Hair: Central balding with thinning hair on temporals. Gray color. Curly texture. No evidence of lice or seborrheic dermatitis.
Skin: Grade 3 sacral ulcer 5cm x 1.5cm, right shin abrasion with dressing intact, otherwise rest of skin warm and moist, smooth texture, good turgor.
Nails: No clubbing, capillary refill <2 seconds in upper and lower extremities
Head: Normocephalic, atraumatic, non-tender to palpation throughout.
Eye Exam
Eyes –No ptosis, strabismus, exophthalmos. Sclera white, cornea clear, conjunctiva pink. PERRLA, EOMs intact with no nystagmus. Does not wear corrective lenses, but per chart does have cataracts OU. Unable to test visual fields due to inability to follow commands
Ear Exam
Symmetrical and appropriate in size. No lesions/masses/trauma on external ears. No discharge/foreign bodies in external auditory canals AU.
Nose & Sinuses Exam
Nose – Symmetrical with no masses/lesions/deformities/trauma/discharge. No discharge noted. Nares patent bilaterally
Mouth & Pharynx (limited exam, this section was extrapolated from chart)
Lips – Pink, moist; no cyanosis or lesions.
Mucosa – Pink; well hydrated. No masses; lesions noted. No leukoplakia.
Palate – Pink; well hydrated. Palate intact with no lesions; masses; scars.
Teeth – Full natural dentition, poor oral hygiene
Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.
Tongue – Pink; no deviation, masses, lesions.
Oropharynx – Well hydrated; no injection, exudates, masses, lesions, or foreign bodies.
Tonsils – present with no injection or exudate. Uvula pink, no edema, lesions
Neck Exam
Neck– Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to
palpation.
Thorax & Lungs:
Chest – Symmetrical, no deformities, no trauma. Respirations unlabored/no paradoxic respirations or use of accessory muscles noted. Lat to Ap diameter 2:1.
Lungs – clear to auscultation bilaterally, no wheezing, stridor or rhonchi.
Cardiac Exam
Heart: Regular rate & rhythm. S1 & S2 are distinct with no murmurs, rubs, or gallops.
Abdominal Exam: round and symmetric, and no scars, striae, or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/iliac or femoral bruits. Pt is non-tender to palpation in all four quadrants. Increased abdominal muscle tone. Non-distended. No rebound tenderness or guarding. Unable to appreciate CVA tenderness or liver span or edge
Neurologic: (exam limited due to patient being observed in bed and requires assistance from multiple nurses to transfer to wheelchair, cognitive impairment, inability to follow commands at times and rigidity; parts of exam extrapolated from nursing and neurology chart notes)
Mental status: Patient is alert; Unable to perform mini-Cog due to cognitive impairment.
Cranial nerves:
CN II: Pupils are 3mm and equal, round, reactive to light bilaterally
CN III, IV, VI: EOM intact in horizontal place, no nystagmus or ptosis
CN V: Facial sensation intact b/l
CN VII: face appears symmetric upon smiling
CN VIII: hearing intact to finger rub
CN IX,X: significant dysarthria, uvula midline, gag reflex intact
XI: unable to assess due to muscle rigidity
CN XII: tongue midline, no fasciculations
Pt has decreased muscle bulk. Difficulty assessing tone as patient not participatory in exam. Strength 4/5 in upper extremities. Moves bilateral lower extremities antigravity. Cogwheel rigidity noted. Cerebellar: Unable to assess as patient not participatory in exam. Unable to assess gait, romberg and pronator drift as pt wheelchair user. Sensory: Reacts to noxious stimuli
Reflexes: Unable to obtain secondary to pt difficulty relaxing extremities.
Peripheral Vascular: Extremities are normal in color and temperature, no edema. Pulses are 2+ bilaterally in upper and lower extremities. No clubbing or cyanosis. No stasis changes or ulcerations noted.
Musculoskeletal: Flexion contractures and rigidity to bilateral knees, bilateral shoulder, elbow, and wrist joints. No soft tissue swelling / erythema / ecchymosis / atrophy. Non-tender to palpation. ROM limited at shoulders, elbows, wrist and knees due to flexion contractures and rigidity. Unable to assess inversion and eversion as pt assessed in bed. No evidence of spinal deformities (noted from nursing notes).
Assessment:
73 y/o male, St. Albans resident with PMH of Parkinson’s disease (on
carvidopa/levodopa), HTN, HLD, dementia, BPH, osteoarthritis, dysphagia, scaitic nerve paralysis, bladder and bowel incontinence s/p decompressive colonoscopy and extensive acute
medical management for Ogilvie Syndrome (now resolved). Pt with poor PO intake due to dysphagia and continues to be at risk for aspiration pneumonia. Continues to be unable to perform ADLS and has cognitive impairment in need of continuation of long-term care. Currently not on treatment for HTN but under control. HLD under control with lipids within normal range.
Plan:
Ogilvie Syndrome, resolved
– monitor bowel routine
Sacral pressure injury and right shin abrasion, no s/s of infection, improving.
-daily wound care to sacrum w/medi-honey cal alginate w/mepilex dressing.
-bacitracin to right shin w/dsd.
-frequent turning in bed every 2 hours & prn.
-monitor.
Diarrhea concerning for overflow incontinence, resolved, s/p decompressive colonoscopy (w/o obstruction) and neostigmine, s/p rectal tube and NG tube
– miralax BID, titrate to 2-3 soft BMs daily, additional dulcolax suppositories
daily-BID PRN
-avoid opiates, anticholinergics
-cont with puree diet
Insomnia
– cont with melatonin 3mg nightly
Dysphagia w/noted downward weight trend
– cont with puree diet, as above
-cont ensure plus
– monitor oral intake
– maintain aspiration precautions
– keep head of bed at 30-45 degrees
– monitor weights weekly
– Multivitamin daily
– nutrition f/u for supplements.
Parkinson’s disease/dementia
– cont with Carvidopa 25/Levodopa 250 mg 2 tab PO BID (7am and 3pm)
– cont holding trazadone PRN due to somnolence
Dry Skin
-c/w petrolatum/mineral oil cream for bilateral legs to relieve dry skin
Osteoarthritis/sciatic nerve paralysis
-cont PROM with maintenance nursing program to maintain/enhance flexibility/strength/functional mobility of the lower extremities and to maintain/enhance ability to perform transfers
BPH, not on medications
-monitor urinary output
HLD – stable
– cont with simvastatin 10mg
HTN, not on tx, stable
-diet controlled
– monitor
Supplement
-d/c vit D3 25mcg
-c/w Multivitamin daily
-ensure plus increased to tid
-c/w magic cup BID
-c/w Juven BID
Prevention
-c/w lovenox for DVT ppx
-check CBC, CMP, lipids, A1c, TSH, B12/folate, Vit D
-maintain routine immunizations
-maintain safety and fall precautions
-cont with monthly weights
