May 2003 Geriatric PresentationMay 2003 Geriatric Presentation

Toby Andrew Hampton, M.D.

Patient IDPatient ID

75 y.o. White maleVeteran admitted to VAMC Mountain

Home Nursing Home on 5/12/2003

Chief Complaint and HPIChief Complaint and HPI

CC: Weakness, Falls, HallucinationsPt. 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 ContinuedHPI 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

PMHPMH

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 ContinuedPMH Continued

Sensorineural Hearing LossShy-Drager SyndromeBenign Prostate HypertrophyChronic ConstipationParkinson’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 AdmissionCurrent Meds on Admission

Aspirin Tylenol SinemetFluocinoloneLatanoprostDaily MultivitaminPRN Nitroglycerin SL

Meds ContinuedMeds Continued

Nitroglycerin patchPramipexoleSeroquelRanitidineSimvastatinSorbitol and Mag Citrate prnAllergic to Pcn and IVP dye

Review of SystemsReview of Systems

20 lb weight loss over past 6 monthsDry eyesCough each am with brown sputumConstipationSome night-time incontinenceArthritic pain in hands, knees, and hips+ Hallucinations, No depression

Physical examPhysical exam

Vital signs Wt. 181.7 lbTemp: 95.3Pulse: L-70; SI-70; St-78Resp: 18BP: L-133/65; SI-119/70; St-94/55

Physical ExamPhysical 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 ExamPhysical 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

Misc.Misc.

MMSE- 26/30Geriatric Depression Scale 2/30Pt. 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 DATAPertinent 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 CourseNursing 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 PlanAssessment and Plan

1. Parkinson’s (Possible Shy Drager)- Cont. Sinemet and pramipexole.

2. Hallucinations- Cont. Geodon and Geropsych is following.

3. Weakness- Cont. PT4. Orthostatic Hypotension- monitor fluid

intake and advise pt. To hold on to something as he stands up slowly to decrease orthostasis.

Assessment and PlanAssessment 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 Shy-Drager SyndromeSyndrome

AKA:”Multiple System Atrophy”

Facts about Shy-DragerFacts about Shy-Drager

Prevalence of 4.4 per 100,00010% as common as Parkinson’s

DiseaseAvg. age of onset 54Predominately Male>Female75% of patients with diagnosis present

with complaints related to autonomic dysfunction.

Autonomic Dysfunction Autonomic Dysfunction SymptomsSymptomsUrinary retention, incontinenceerectile dysfunctionorthostatic hypotensionapnea, or inspiratory stridorsnoring or loud respirationInability to sweatResistance to levodopa

Movement PresentationMovement 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.

TreatmentTreatment

Dietary increases of salt and fluidL-Dopa may be useful in some casessympathomimetic aminesNSAIDSsalt-retaining steroidsalpha-adrenergic medsSleeping in a head up position reduces

am orthostatic hypotension

PrognosisPrognosis

Progressively fatal diseaseDeath usually occurs within 7-10

years of diagnosisDeath usually ensues secondary to

stridor, aspiration pneumonia, or cardiac arrest.

The End The End