Psych Eval History & Physical Discharge Summary Chemistries CBC's CXR's
Living Will / Medical Treatment Plan EKG Graphic Chart Nursing Admission Assessment
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Brief History and Hospital Course
This 72 year old white female who had history of severe dementia, depression, agitation and combativeness suffered thalamic CVA in 1989, six years PTA, and had history of severe chronic low back pain after disc surgery, treated generally with opiates daily for years. She had chronic hyponatremia secondary to psychogenic polydipsia; she was reported to drink even from toilets, when on therapeutic fluid restriction, unless restrained. She also had history of HTN, PUD, meningitis, TIA’s, and psychotic depression. On admission her medications included Dyazide, Lasix, Glucotrol, Hyphen, Lopressor, Zantac, prn Lortab, as well as Thorazine, Zoloft, Tranxene, and prn Xanax.
Previous medications were continued but Duragesic patch 25 mcg./hour then 50 mcg./hour was substituted for Hyphen and Lortab. K-Dur was added, and Risperdal and Serzone were substituted for her previous psychotropics; she also was given trazodone for sleep. A UTI was treated with Cipro, Dyazide was discontinued, and hyponatremia treated with fluid restriction. Despite these measures, her psychiatric symptoms continued.
A rectovaginal fistula was discovered, GYN consulted, and she was started on Keflex. Because of history of possible seizure disorder, and valproate’s effect with aggressive agitation, Depakene was added. The patient continually complained of pain; moaning, groaning, and screaming, and had morphine prn’s given by the nurses, then Duragesic patch increased to 75 mcg./hour.
On about the eighth hospital day, on the 4th, the patient apparently aspirated; CXR was clear but clinically she had breathing and airway problems and was choking on her food. This continued and then on 1/7, her eleventh hospital day, she became acutely and seriously ill, with hypernatremia (sodium of 159) white count up at 15K, hypotensive, and oxygen saturation of only 70 to 80. CXR showed a possible infiltrate. She appeared septic, secondary either to aspiration or the rectovaginal fistula, despite Keflex started previously.
The patient’s family refused aggressive intervention, and an IV was not started, following her Medical Treatment Plan. All medications, including her Duragesic patch, were ordered discontinued. She did have ordered and received two doses of morphine 5 mg. IM at that point (Go to Merck Manual>>), apparently in conjunction with the Duragesic, which the nurses failed to remove and which was found at autopsy. She died the evening of the 7th.
