Event 1: History of Present Illness

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Summary

Mrs. Rose is an 89-year-old, widowed white female who has resided in a nursing home for the past 3 months.  Admission was precipitated by inability to function independently, related to Dementia Alzheimer’s –type (DAT) and to widespread arthritic pain.  Her mobility is severely limited—she spends most days sitting in a dayroom by the nursing station.  Aside from DAT and osteoarthritis (thoracic, lumbar, hip, knee), other diagnoses include Type 2 Diabetes Mellitus, coronary artery disease, depression, and essential hypertension.  She takes multiple medications for her disorders, but no routine analgesic.  She does have acetaminophen PRN on order but has not taken any for several months according to MAR review.

History of Present Illness

Mrs. Rose has been a resident in a long-term care facility for 3 months.  She was admitted with a primary diagnosis of dementia of the Alzheimer’s type (DAT) with several secondary diagnoses, one of which is widespread osteoarthritis. Mrs. Rose is largely inactive.  She recognizes her niece, Maria, who visits weekly, but few others.

Mrs. Rose has been intermittently agitated since her admission.  The agitation initially was ascribed to the change in surroundings, but the agitation has persisted. Although there are a number of measures available (for a current review, see: http://prc.coh.org/PAIN-NOA.htm),  the nursing facility to which Mrs. Rose was admitted uses the Checklist of Nonverbal Pain Indicators (CNPI) as a tool for assessing possible pain-related behaviors.  Her CNPI score reflects a range of pain behaviors: 1) she often frowns, moans, and rubs her lower back when sitting in the day room; 2) she typically props against a wall when she moves around; 3) she is uncooperative with assisted ADLs, clenching her teeth and telling the assisting staff to stop; 4) she often can’t sit still after such ADLs as bathing.  She also awakens after several hours sleep and then demonstrates disrupted sleep throughout the night. 

Her Mini-Mental Status Exam (MMSE) is 12/30.  Despite her limited cognitive capacity, she was reasonably independent in self-care until the year prior to her admission to the long-term care facility.

Mrs. Rose’s MMSE

 

Scoring for the Mini-Mental Status Exam

25-30 normal cognition

21-24 mild dementia

10-20 moderate dementia

< 9 severe dementia

Physical Exam

Vital signs

Temperature 97.2, Blood Pressure 142/88, Heart Rate 90, oxygen saturation 98% on room air, Height 64 inches, Weight 125 lbs (56.8 kg)

General

Alert, agitated, oriented to place only.  Well-developed thin woman.

HEENT

PERRLA, TMI, oropharynx clear, thyroid midline and anodular, tongue midline and mobile, NCAT, sclera anicteric.  Decreased mouth opening and jaw ROM with apparent tenderness over the TMJ bilaterally (patient winces).  Dentures are out, gums are red and swollen.

CV / Pulm

RRR, no m/g/r, CTA bilaterally

Abd

Soft, no masses, no guarding, rebound, or tenderness on palpation.  Positive bowel sounds X 4 quadrants, no bruits or thrills, visible scar from previous surgery

GI/GU: examination deferred due to patient resistance

Musculoskeletal

Mild kyphosis and lordosis, heberden’s nodules on multiple DIPs bilaterally, visual discomfort on FABER, non-cooperative with straight leg raise or ROM assessment.  Visible discomfort with palpation of the paraspinal muscles L3-L5.  Strength estimated 4/5 upper and lower extremities

Extremities

No clubbing, cyanosis, or edema. 1+ pitting edema of LE

Integumentary

No rashes, petechiae, or bruising.  Normal skin turgor.

CNS

Distracted and non-interactive.  MMSE =12, CN II-XII grossly intact, DTR +1 LLE, DTR+3 RLE.  Gait antalgic on left

Definitions

HEENT

Head, ears, eyes, nose, throat

PERRLA

Pupils equally round and reactive to light and accomodation

TMI

Tympanic membranes intact

NCAT

Normocephalic, atraumatic

Anicteric

Without yellowing (a frequent sign of hepatic disease)

ROM

Range of motion

TMJ

Temporomandibular joint

CV / Pulm

Cardiovascular / pulmonary system

RRR

Regular rate and rhythm

m/g/r

Murmors, gallops, rubs

CTA

Clear to auscultation

Abd

Abdomen

DIP

Distal interphalangeal joint

FABER

Flexion, abduction, external rotation (also called Patrick’s Fabre)

L3-L5

Refers to the level of vertebral body on the lumbar spine

MMSE

Mini mental status exam

CN

Canial nerves

DTR

Deep tendon reflexes

LLE

Left lower extremit

Medical, Social, and Family History

Past Medical History

• Dementia of the Alzheimer’s type
• Osteoarthritis
• Type 2 Diabetes Mellitus
• Coronary Artery Disease
• Depression
• Essential hypertension

Past Surgical History

L4-L5 discectomy (2003)

Social History

Mrs. Rose smoked one pack of cigarettes/day for 40 years, but has not smoked since her husband’s death.  She was known to enjoy social drinking.  There is no history of other substance use.

Family History

There is a history of heart disease and DAT in the family.  Mrs. Rose’s spouse died approximately 10 years ago, and there were no children by the marriage.  Unconfirmed report of Bipolar Type 1 in sibling.  Power of attorney held by niece.

Medications

Current Medications

• Acetaminophen 325mg PO every 6 hours as needed for pain
• Metformin 1000mg PO every 12 hours
• Lisinopril 20mg PO every morning
• Metoprolol Succinate 50mg PO every morning
• Donepezil 10mg PO at bedtime
• Fluoxetine 20mg PO at bedtime
• Quetiapine XR 300mg PO every 12 hours
• Sennosides – docusate 8.6mg/50mg  PO 1 tablet Q12 hours as needed
• Cholicalciferol 1,000 IU PO daily
• Naproxen 500mg PO every 12 hours as needed

Allergies

Codeine (pruritus)

Social Work and Behavioral Health

Mrs. Rose was married x 49 years.  Her spouse died approximately 10 years ago.  There were no children by the marriage, and Mrs. Rose’s siblings (she had 1 brother and 1 sister) also have died. Mrs. Rose is a retired bookkeeper.  Since her husband’s death she volunteered at the hospital, but quit doing that when she was not able to drive. Up until the admission at the LTC facility she was living alone with her  nieces’ assistance, a visiting nurse, a personal care assistant and meals-on wheels. 

Social Work Note

Mrs. Rose, a widow with no children, was married x 49 years.  Her spouse died approximately 10 years ago from cancer after being cared for by his wife over a five year period. Mrs. Rose’s  brother and sister are dead and the singular relative with whom she continues to be close is niece, Maria, who is divorced, works full-time and cares for three children. Maria is Mrs. Rose’s primary family contact, her health care power of attorney and the link to Mrs. Rose’s history, legacy and values.

Mrs. Rose, a high school graduate, was the bookkeeper in a  “mom and pop” grocery store owned by the Roses in a small town in Illinois. The couple closed the store and retired almost 25 years ago. They then both volunteered at the local hospital and for their church as they were active and devoted Catholics. Mrs. Rose had an extensive community of church friends, but many have predeceased her and others no longer travel independently. She was the church organist and taught piano lessons in her home until her husband became ill. After her husband’s death, she volunteered at the hospital, until she was unable to drive due to her cognitive decline and increasing pain.

Until her admission at the LTC facility, she was living alone with assistance from her niece for shopping and transportation, a personal care assistant twice a week , monthly visits from a church parish nurse, and meal-on-wheels. Until the last few months, and when her arthritic pain was controlled, Mrs. Rose was essentially self-care and independent in ADL, needing assistance with shopping, housekeeping and meal preparation. More recently she sat on the couch most of the day in front of the TV, and needed to be coached to eat or drink. Mrs. Rose became increasingly confused, disoriented, and ADL dependent which led to her admission to the LTC facility.

Maria reports that her aunt has Medicare A, B & D with no Medicare supplement. She receives Social Security with no additional pension.  She has limited savings. Assets include a house with few additional assets as the couple lost money when they sold the store. They have donated heavily to religious charities.

Several years ago, Mrs. Rose signed a health care directive and she has chosen a DNR order at this LTC facility.. Mrs. Rose, however, did not give her niece financial power-of-attorney but allowed Maria to help pay bills. Mrs. Rose was accepted into the LTC facility with pending Medicaid while Maria pursues possible guardianship and control over her aunt’s financial affairs. Maria needs assistance to pursue the legal and financial aspects of her aunt’s life in order to diminish frustration and the consequent strain on her family.

Her niece reports that Mrs. Rose generally was a positive and friendly person. She also reports a suspicion that Mrs. Rose sometimes would use her arthritic pain to get attention. She and her aunt’s friends were never certain if she was “crying wolf” or in “real pain”. Several times before her husband died, Mrs. Rose stated that she was “in the worse pain in her life”, but would cheerfully enjoy the car ride to the emergency room, and wink, noting “my doctor understands me” when admitted for observation. Maria believes that her aunt used her pain as a manipulative tool to have a respite from caring for her husband. Maria states that she has had great difficulty accepting that her aunt truly was in pain and in taking this whole “pain thing” seriously.

Assessment

Mrs Rose spent her adult life interfacing and serving others in her work and in her volunteer roles in hospital and church. Her life prior to her husband’s illness and death included social contacts through her work, volunteering and teaching of music. Her history indicates that when pain was controlled she was more functional and independent in here ADLS.

Interventions

Maximize Mrs Rose’s investment in music, spiritual and religious ritual as therapeutic resources to be  incorporated into a pain treatment plan that responds to personhood,

Seek collateral information from staff and niece to deepen understanding the meanings of Mrs Rose’s pain behaviors in order to assist staff and assure the niece that the treatment plan will meet the comprehensive multidimensional needs of a patient with dementia and pain. 

Consider whether an aspect of Mrs Rose’s behaviors  (sat on the couch most of the day in front of the TV, and needed to be coached to eat or drink) was influenced not only by cognitive changes but also a response to the perceptions of her support system that she was consciously manipulating them.

Assist niece with psycho-education and reframing to reconsider the meaning of her aunt’s pain behaviors from “manipulation and crying wolf” to consider that perhaps:

• Seeking treatment for pain was the only acceptable path to “respite:” from the care of her dying husband.
• Her pain became a primary focus after the loss of her husband, and social networks.
• The expected pain related to her diagnoses provided an avenue for her to re connect with her hospital network,  a place where she had relationships of meaning and contributed to the lives of others,
• Rather than being manipulated, Maria may have been meeting her aunt’s need for pain management as well as her need to feel valued and cared for in a setting, where she could allow herself to be cared for. 

Further assessment of depression given profound losses in her life, including her home, husband, social network etc.

Assist niece with financial aspects of patient’s care to diminish family distress.

Pertinent Nursing Domains and Findings

Communication

Unable to communicate verbally

Perception/cognition

Unable to determine due to impaired verbal communication.

Self-perception

Unable to determine due to impaired verbal communication

Coping/stress tolerance

History of anxiety and stress/pain overload per history provided by niece

Comfort

History of degenerative arthritic changes, and the medication administration record, this patient evidences both persistent) pain and under medication for pain.

Activity/Rest

Patient groans or cries when walking or when walking attempts are made, thus limiting her mobility.

Disturbed Sleep Pattern Related to Pain

Patient awakes after approximately two hours of sleep and then sleeps intermittently for rest of the night.

Safety/protection

Patient attempts to rise and walk to bathroom, but limps or has difficulty taking steps. Leans over and rubs knees. Seems unsteady on feet. Resists change in position when sitting in wheelchair or when lying in bed. Again, groans with movement.

Elimination

Bowel movements are not regularly evaluated in patient record nor is the patient’s oral fluid intake. This leaves the patient at risk for constipation and for dehydration (deficient fluid volume).

Role relationships

At times recognizes niece, but often does not. Does not seem to know who the nurses are. Does not initiate interaction, even non-verbally. All interactions seem to be in reaction to nurse assistants or nurses attempting to move patient to change position or encourage walking.

Lab Results

Obtained on admission to LTCF 3 months ago:

Comprehensive metabolic panel (14):

Glucose, Serum

92mg/dL (normal range:  65-99mg/dL)

BUN

19mg/dL (normal range: 6-24mg/dL)

Creatinine, Serum

0.86mg/dL (normal range:  0.57-1.00mg/dL)

BUN / SCr ratio

22 (normal range: 9-23)

Sodium, Serum

136mmol/L (normal range: 134-144mmol/L)

Potassium, Serum

4.4mmol/L (normal range: 3.5-5.2mmol/L)

Chloride, Serum

101 mmol/L (normal range:  97-108mmol/L)

Carbon Dioxide, Total

22mmol/L (normal range: 20-32mmol/L)

Calcium, Serum

9.8mg/dL (normal range: 8.7-10.2mg/dL)

Protein, Total, Serum

4.9g/dL (normal range: 6.0-8.5g/dL)

Globulin, Total

1.3g/dL (normal range: 1.5-4.5 g/dL)

Bilirubin, Total

0.4g/dL (normal range: 0.0-1.2mg/dL)

Alkaline Phos

175  IU/L (normal range: 25-150IU/L)

AST (SGOT)

55IU/L (normal range: 0-40 IU/L)

ALT (SGPT)

70IU/L (normal range: 0-32IU/L)

Magnesium

2.0mg/dL (normal range: 1.7-2.2mg/dL)

Vitamin B12

347pg/mL (normal range: 211-946pg/mL)

Folate

14.8ng/mL (normal range: > 3.0ng/mL)

Albumin, Serum

2.9g/dL (normal range: 3.6-4.8g/dL)

Fasting Lipid Panel:

Cholesterol, Total

222mg/dL (normal range: 100-199mg/dL)

Triglycerides

152mg/dL (normal range: 0-149mg/dL)

HDL Cholesterol

53mg/dL (normal range: >39mg/dL)

VLDL Cholesterol

30mg/dL (normal range: 5-40mg/dL)

LDL Cholesterol

112mg/dL (normal range: 0-99mg/dL)

Hemoglobin A1c

7.4% (normal range: 4.8-5.6 %)

Thyroid Stim Horm

6.5uIU/mL (normal range: 0.45-4.50uIU/mL)

Complete Blood Count without Differential

WBC

7.5cnt/uL (normal range: 4.0-10.5cnt/uL)

RBC

5.3cnt/uL (normal range: 4.1-5.8cnt/uL)

Hemoglobin

10.9g/dL (normal range: 12.6-17.7g/dL)

Hematocrit

33.2% (normal range:37.5-51.0 %)

MCV

105fL (normal range:  79-97fL)

MCH

29.4pg (normal range: 26.6-33.0pg)

MCHC

33.1g/dL (normal range:  31.5-35.7g/dL)

RDW

13.9% (normal range: 12.3-15.4%)

Urinalysis, Complete

Urinalysis Gross Exam

Specific Gravity

1.025 (normal range: 1.005-1.030)

pH

7.0 (normal range: 5.0-7.5)

Urine-Color

Yellow (normal color: yellow)

Appearance

Clear (normal appearance: clear)

WBC Esterase

Negative (normal: negative)

Protein

1+ A (normal range:  negative/trace)

Glucose

Negative (normal: negative)

Ketones

Negative (normal: negative)

Occult Blood

Negative (normal: negative)

Bilirubin

Negative (normal: negative)

Urobilinogen, Semi-Qn

1.0mg/dL (normal range: 0.0-1.9mg/dL)

Nitrite, Urine

Negative (normal: negative)

Microscopic Examination

WBC

0-5/hpf (normal range:  0-5/hpf)

RBC

0-3/hpf (normal range: 0-3/hpf)

Epithelial Cells (non-renal)

0-10/hpf (normal range: 0-10/hpf)

Mucus Threads

Present (normal: not established)

Bacteria

Few (normal: none seen/few)

Imaging Studies and Diagnostic Tests

Two view Plain film radiograph of hands (films and report) April 1999

 

Impression

Degenerative change without acute fracture.

History

Left wrist pain following a fall.

Left wrist, 2 views.

Findings

Left wrist in 2 views shows no evidence of acute fracture or subluxation. Degenerative changes are noted within the intercarpal joints.

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Plain film radiograph of knee (film and report) April 1999

Impression

Three-compartment degenerative osteoarthritic change, slightly worse as compared to the prior study.

History

Bilateral knee pain.

Radiographs of the left and right knee

Comparison

Prior study 06/09/95.

Findings

Ap and lateral weightbearing views of the left and right knee were obtained. Left knee demonstrates large enthesophyte along the anterior superior margin of the patella.  There is periarticular spurring of the patella with irregular subchondral lucency articular surface of the patella superiorly consistent with osteochondral injury or defect.  There is mild periarticular spurring of the femoral condyles and tibial plateau.  The degenerative osteoarthritic changes have progressed in the interval.  There is no fracture.

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MRI without contrast (report only) August 2002

Impression

Broad-based disc protrusion causing bilateral neural foraminal stenoses at the l5-s1 level.

History

Chronic low back pain without injury.

MRI l spine w/o

Comparison

None.

Findings

The kidneys, aorta and paravertebral tissues appear normal.  The vertebral alignment is anatomic.  There is no bone marrow edema.  The intervertebral discs appear normal from the t10-11 through l4-5 levels. At the l5-s1 level, the intervertebral disc demonstrates a broad-based protrusion, with effacement of the anterior epidural fat.  There is moderate to severe impingement on both distal nerve roots within the neural foramina at the l5-s1 level.  There is no central canal stenosis.  The facets are display mild to moderate multi-level osteophytic changes.

Plain film radiograph of pelvis (film and report) May 2008

Impression

Normal osseous structures of the pelvis and hips. 

History

Right buttock and low back pain

Ap pelvis and 2 views right hip 

Findings

There is no evidence of fracture or dislocation present.  Bones  are of anatomic alignment. 

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Cardiac stress test July 2005

Stage

Rest

• HR: 96
• BP: 160/84

Peak

• HR: 153
• BP: 180/90

Summary

The left ventricle cavity size is normal.

The left ventricle has mild to moderate concentric hypertrophy.

Global left ventricle systolic function is normal.

The right atrium cavity size is normal.

Mitral valve leaflet mobility appears normal.

Chordal systolic anterior motion is visualized. Peak velocity through LVOT is 3.7 m/s. Maximum PG of 56 mmHg. Mean PG of 17 mmHg.

Patient followed a Bruce protocol.

The total exercise duration was 4mins 30 secs.

Exercise capacity is poor.

The patient achieved a level of 7 METS.

Non-specific ST changes are noted.

This is a negative electrocardiographic stress test.