Mr. Frank’s Test Results
Before beginning the first module category of Initial Diagnosis, review the following:
Mr. Frank's Lab Results
UA with Reflex Culture
| Component | Value | Reference Range |
|---|---|---|
| Color UA | Straw (A) | Pale to dark yellow |
| Clarity UA | Clear | Clear |
CBC with Diff
| Component | Value | Reference Range |
| WBC | 5.5 | 4.0-9.5 K/uL |
| RBC | 4.59 | 3.90-4.90 M/uL |
| Hemoglobin | 14.1 | 11.8-14.8 g/dL |
| Hematocrit | 42.3 | 35.5-44.0% |
| MCV | 92.2 | 82.0-99.0 fL |
| MCH | 30.7 | 27.2-32.6 pg |
| MCHC | 33.3 | 30.0-36.0 g/dL |
| RDW | 13.3 | 11.5-14.5% |
| RDW-9TDEV | 44.4 | 37.1-48.7 IL |
| Platelets | 187 | 140-350 K/uL |
| MPV | 12.1 | 9.3-12.4 fL |
| Neutrophils | 48 | 45-70% |
| Lymphocytes | 39 | 16-45% |
| Monocytes | 8 | 3-13% |
| Eosinophils | 6 | <7% |
| Basophils | 0 | <3% |
| Neutrophil Absolute | 2.62 | 1.90-7.00 K/uL |
| Lymphocyte Absolute | 2.11 | 0.70-4.50 K/uL |
| Monocyte Absolute | 0.41 | 0.10-1.30 K/uL |
| Eosinophils Absolute | 0.30 | <0.70 K/uL |
| Basophils Absolute | 0.02 | <0.30 K/uL |
Comp. Metabolic Pnl
| Component | Value | Reference Range |
|---|---|---|
| Sodium | 144 | 136-145 mmol/L |
| Potassium | 4.9 | 3.5-5.0 mmol/L |
| Chloride | 106 | 98-107 mmol/L |
| CO2 | 25 | 22-29 mmol/L |
| Calcium | 9.3 | 8.6-10.2 mg/dL |
| Bun | 23 | 8-23 mg/dL |
| Creatinine | 0.83 | .51-95 mg/dL |
| Glucose | 98 | 799-99 mg/dL |
| Total Protein | 7.1 | 6.7-8.6 g/dL |
| Albumin | 4.5 | 3.5-5.2 mg/dL |
| Bilirubin Total | 0.3 | 0.2-1.1 mg/dL |
| Alkaline Phosphatase | 60 | 35-104 U/L |
| AST | 20 | <33 U/L |
| ALT | 21 | <34 U/L |
| GFR | >60 | ml/min/1.73 sq |
Note: The GFR result is not clinically significant on patients <18 or >70 years of age.
CT Scan
Mr. Frank's Medical History
Mr. Frank is an 73 year old nursing home resident. Recent years have been marked by progressive cognitive decline attributed to Alzheimer’s disease. Over the past 12 months he has become non-ambulatory and now uses few words most often out of context. He does still feed himself and swallows without difficulty. He is typically “pleasantly confused” and compliant with staff guidance and care.
Mr. Frank was previously a primary school teacher and was well-loved within his community. His husband Bennie passed away in his late 60’s. They have one adult daughter who visits regularly but does not live nearby. His daily care is provided by the nursing home staff.
2 days prior to admission, the nursing home staff noted decreased oral intake and resistance to care but were able to dose usual medications. This progressed over the subsequent day with Mr. Frank noted to be agitated, resistant to care and uncharacteristically aggressive – striking out at the aid who came to clean him up after breakfast. Transfer to acute care facility was arranged after Mr. Frank fell from his chair.
Mr. Frank was evaluated in the emergency department prior to admission.
Medications
- Docusate sodium 100 mg daily
- Donepezil 10 mg daily
- Memantine 10 mg BID
Physical Exam
VS
- BP: 110/78
- Pulse: 110
- Respirations: 18
General
Clean but slightly disheveled older male, no acute distress. Does not respond to questions, appears alert but inattentive
HEENT
No contusion or indication of trauma, PEERL, fundoscopic exam with normal optic vessels and disc, face symmetrical, tongue midline
Neck
No mass, lesion or point tenderness
Chest
Good air movement, no crackles or wheezes
CV
RRR, rate 110, no murmur, extra sounds or rub
Abd
Normoactive bowel sounds, soft, no organomegaly or tenderness. No costovertebral angle tenderness.
Rectal Exam
No mass, no impaction, heme negative stool
GU
No lesion or mass
Extremities
Mild ecchymosis R elbow, ROM all joints without evidence of discomfort, some resistance to exam
Skin
Sacral stage 3, red base no purulence, patient with obvious discomfort when examined. Mild tenting of forearm skin.
Work up ordered by emergency physician include CBC, chemistry, UA, blood cultures, toxicology, chest X-ray, computed tomography (CT) head.
He was admitted for further evaluation. Initial efforts have included parenteral hydration and empiric antibiotics.
Initial Team Rounding
The following shows your peers, Victor, Lily, and Malcolm, as they discuss Mr. Frank’s case.
Diagnosis
Now that you reviewed your peers’ insights into Mr. Franks case, what are some diagnoses you feel are appropriate to work up for Mr. Frank? Victor, Lily, and Malcolm give their responses below:
Victor: “I would be thinking about infection, pain, and polypharmacy.”
Lily: “Likely a CVA, atypical migraine, and brain tumor.”
Malcolm: “I would consider tertiary syphilis, autoimmune encephalitis, or medication error.”
In this case, Victor’s response of infection, pain, and polypharmacy seems the most reasonable answer for potential diagnosis of Mr. Frank’s discomfort.
Pain Evaluation
Now that you’ve gone over Mr. Frank’s medical history and physical, we can confirm he’s at significant risk for pain, and this must be assessed. Which of your peers do you feel offers the best strategy to evaluate for pain in nonverbal older adults? Victor, Lily, and Malcolm offer their opinions below.
Victor: “Utilize a functional MRI to evaluate whether someone is in pain.”
Lily: “I’ve read about approaches to evaluating pain in non-verbal individuals. There are tools we can use.”
Malcolm: “You can’t really evaluate for pain, but we could try treating him to see if he gets better.”
Lily’s thoughts on assessing pain offer the best strategy to assess Mr. Frank for pain.
Feedback
From reviewing Mr. Frank’s history and physical, we can confirm he’s at significant risk for pain, and this must be assessed. Fortunately, there are numerous tools to evaluate pain in this population. The main tool used in this module is the PAINAD.
The PAINAD Assessment Tool can be accessed here:
http://dementiapathways.ie/_filecache/04a/ddd/98-painad.pdf
The Pain Assessment Checklist for Seniors with Limited Ability to Communicate I and II, otherwise known as PACSLAC I and PACSLAC II both provide a pain assessment checklist for seniors with limited ability to communicate. The Comprehensive Pain Assessment form lets you note details about pain location, duration, variations, and rhythm. The Abbey Pain Scale can also be used to measure pain in people with dementia who cannot verbalize.
The PACSLAC I checklist can be accessed here:
The PACSLAC II checklist can be accessed here:
The Comprehensive Pain Assessment Form can be accessed here:
The Abbey Pain Scale can be accessed here:
http://prc.coh.org/PainNOA/Abbey_Tool.pdf
PAINAID Practice 1
Watch the video before answering the following question about his result in the PAINAID.
Test Your Knowledge
How would you rate Mr. Frank’s pain in the PAINAD Practice 1 scenario above using the PAINAD scale?
PAINAID Practice 2
Watch the video before answering the following question about his result in the PAINAID.
Test Your Knowledge
How would you rate Mr. Frank’s pain in the PAINAD Practice 2 scenario above using the PAINAD scale?
PAINAID Practice 3
Watch the video before answering the following question about his result in the PAINAID.
Test Your Knowledge
How would you rate Mr. Frank’s pain in the PAINAD Practice 1 scenario above using the PAINAD scale?
