PHOTO>>Psych Eval History & Physical Discharge Summary
Living Will / Medical Treatment Plan
Physician's Orders Progress Notes Nursing Staff Notes
COLORS: RED - PAIN ORANGE - AGITATION GREEN - TERMINAL
Brief History and Hospital Course
This 90 year old widowed white female had a two week history of severe agitation, was highly combative, restlessly wandering, spitting and scratching, and appeared deeply dysphoric, all this after a severe parietal stroke four weeks prior to admission, with probable thalamic component, superimposed on long-standing dementia. She had been at Rocky Mountain Care Center before the stroke but was too aggressive for return. She had medical history of unstable angina, atrial fibrillation, HTN, CHF, and myocardial infarction, and had recently received Darvocet for chest pain in the months before admission. Other medications included Lasix, KCl, Lanoxin, Normodyne, Vasotec, and Haldol 0.5 mg. tid, with another 1 to 2 mgs. prn, and Serzone 100 mg. bid.
She had a history of 30 lb. weight loss in the recent months. (Photo)>>
On admission 12/20/95 she continued on prior medication but Risperdal 0.5 mg. tid was substituted for Haldol, with Haldol the default antipsychotic, given IM, when the patient frequently refused oral medication. Cipro was given for a UTI. Depakene was added, then trazodone, and then psychotropics were gradually increased in response to symptoms. Finally, clonidine patch was added to try to control continued serious aggression and agitation. Despite all of this, symptoms continued, with the patient "…very agitated...striking at staff…" on 1/5, and "…attempting to remove diaper..." and "ambulating, (but) feeding poorly…" on 1/6. The patient repeatedly refused oral medication, food, and fluid throughout the hospitalization.
On 1/7, her nineteenth hospital day, she was weak, not taking fluids or nourishment, and her urine output dropped to zero. Family discussion was held, and the family directed that all interventions be withheld. At this point the patient was understood by the physician to be terminal. All previous medications were stopped. Morphine 5 mg. IM q3hr was started, and this was increased to 10 mg. q3hr the next day, 1/8 (Go to Merck Manual>>), when she died. Her weight, 116 on admission, was 108 at death.