Psych Eval Discharge Summary Living Will / Medical Treatment
Plan
Physician's
Orders Progress
Notes Nursing Staff Notes
Nursing
Admission Assessment
Medication Administration Record Phone Intake
COLORS: RED - PAIN ORANGE - AGITATION GREEN - TERMINAL
Brief History and Hospital Course
This was a 91 year old widowed white female with a long history of severe dementia, who had lived at Pioneer Care Center for some time. Over the past 6 months she had appeared extremely anxious, reportedly screaming constantly, this was treated with (subtherapeutic doses of) Xanax and amitriptyline. She had history of CAD and CHF, and was on NTG, Lasix, and KCl. She had severe osteoporosis, with hip fracture 6 months prior to admission, and history of ankle and wrist fractures, as well as spinal compression fractures. At the nursing home she received occasional prn Lortab, but mostly just Tylenol for pain.
On admission she was ordered to be continued on her usual medications, and trazodone 150 mg. qhs was added for sleep; however, she took no oral medications during the hospitalization; she refused all those given. At 7:30 PM, three hours after her admission, the charge nurse called and got a telephone order for morphine 10 mg. IM, citing what appeared to her to be the patient’s "severe pain (patient becomes rigid and screams when touched) related to profound osteoporosis". (Go to Merck Manual>>) The patient did well for the next four hours – "…was calmer…after morphine…very needy…", indicating normal pharmacodynamics for her age. At 3:30 AM, about eleven hours after admission, a different nurse called the physician to report the patient was "moaning and screaming"; the nurse said the patient was in severe pain and another morphine 10 mg. IM was given; the patient then "appeared to sleep." At about 5:45 AM an EKG and CXR were done; EKG showed sinus tachycardia with marked sinus arrythmia, CXR revealed consolidative hilar densities suggestive of bilateral infiltrate (autopsy later showed patient had pneumonia at death). At 7:30 AM the patient was reportedly "…resting in bed…respirations 12…not responsive to verbal or tactile touch (sic)…able to blink eyes", but at 8:55 AM she was found: "Patient with no respirations and no heart rate for 5 minutes". Death was ascribed to probable myocardial infarction, but acute pneumonia is seen as more likely, with the benefit of the later autopsy results. It was 5 hours 25 minutes between the second of two doses of morphine and her death.