Ellen Anderson
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 ordered 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". 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, and acute pneumonia is seen as contributory, with the benefit of the later autopsy results. The record as to time of morphine administration, 5 hours 25 minutes antemortum, speaks eloquently to the non-role of opiate in her death.
Ellen Anderson Phone Intake
MEDICAL
TREATMENT PLAN
I, (signed)Michael H. Sumko , certify that I
am the attending physician for ELLEN T., Anderson
of Brigham City, Utah , who is presently under
my care this 17 day of July , 1995
and who has been under my care since the 19 day of June , 1995.
The declarant, the above names patient, is currently suffering from the following injury, disease or illness: Right hip fracture
I certify that I have explained to the declarant to the extent he/she is able to understand and to all available persons acting as proxy, the reasonable available alternatives for care and treatment. I certify that the care and treatment alternatives directed below are:
________directed by the declarant; or
________ that the declarant has a physical or mental condition which renders him or her unable to give personal direction for care and treatment and that the care and treatment alternatives directed below are in my opinion, and in the opinion of the declarants proxy, what the declarant would probably decide if able to give current direction concerning his/her care and treatment.
Date:_17/July /95 (Signed)Michael H. Sumko, M.D.
Attending Physician
The following care and treatment is directed with respect to the declarant:
Withhold treatment of oxygen therapy, respiratory treatments, suctioning, mechanical ventilation, ventilatory support, CPR, chest compressions, cardiac medications during CPR, defibrillation, chemotherapy, radiation, surgery, IV fluids, NG, gastric tube and speak with authorized agent before using antibiotics
Daughter (Signed) Barbara A. Poelman
Relationship to declarant of any agent signing Signature of declarant or authorized
for declarant agent
901 Douglas Drive Brigham City, Box Elder County, Utah 84302
Address of signer, including city, county and state of residence
Ellen Anderson Nursing Admission Assessment Page 1
Ellen Anderson Nursing Admission Assessment Page 2
Ellen Anderson Nursing Admission Assessment Page 3
Ellen Anderson Nursing Admission Assessment Page 4
Ellen Anderson Nursing Admission Assessment Page 5
Ellen Anderson Nursing Admission Assessment Page 6
Ellen Anderson Nursing Admission Assessment Page 7
Ellen Anderson Nursing Admission Assessment Page 8
Ellen Anderson Nursing Admission Assessment Page 9
Ellen Anderson Nursing Admission Assessment Page 10
Ellen Anderson Nursing Admission Assessment Page 12
Ellen
Anderson Nursing Staff Notes
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12/29/95 |
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New admit. |
Ellen
Anderson Progress Notes
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12/29/95 |
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Psychiatric evaluation done and dictated. Diagnosis: Anxiety disorder
not otherwise specified, major depressive disorder with psychotic
features. Plan; medical evaluation, benzodiazepines vs. antidepressants,
possible Risperdol. Morphine sulfate for
discomfort. Robert Weitzel, M.D. |
Ellen
Anderson Physician Orders
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12/29/95 |
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I CERTIFY THAT THIS PATIENT
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Response - Patient calmer 2 hours after
Morphine Sulfate injection; very needy
of staff attention. Screams when left alone, if awake speech becomes
inarticulate |
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12/30/95 0315 0330 |
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Patient's respirations have been very erratic
and ranging form 8 to 16 per minute. Blood pressure 70/50. Pulse
120. Dr. Weitzel paged and nursing supervisor informed of patient's
condition. |
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24 hour check 12/30/95 0445 TS RN Ellen Anderson EKG
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Ellen Anderson Chest X-Ray
Ellen Anderson Graphic Chart
630 Patient has appeared to sleep since receiving Morphine Sulfate - respirations remain erratic. EKG and Chest x-ray done. Side rails up x 2. Bed check monitor in place. T. Scholl, RN
730
Patient resting in bed. Vital signs: temperature 97.9, respirations 12,
pulse 60. Unable to get blood pressure. Patient not responsive to verbal and
tactile touch. Patient able to blink eyes. Family notified in Brigham City of
patient's decline but get answering machine and left message to contact Davis
(continued)
Bonnie Hardy, RN
(Continued) hospital. Bonnie Hardy, RN
12/30/95
0855 Patient with
no respirations, no heart rate for 5 minutes. Dr. Weitzel
notified. Nursing supervisor notified. Awaiting return call from only
relative listed in chart with phone
number.
920
Family member returned call, notified of patient's condition.
Family stated they were on their way and hung up phone. Bonnie
Hardy, RN
1120 Family arrived, gathered personal belongings. Requested body be sent to Meyers Mortuary in Brigham City. Arrangements made. Bonnie Hardy, RN
1320 Mortician
arrived and transported body and signed for receipt of body.
Bonnie Hardy, RN
Ellen Anderson - Medication Administration Record, page 1
Ellen Anderson - Medication Administration Record, page 2
DAVIS HOSPITAL & MEDICAL CENTER
PSYCHIATRIC EVALUATION
PATIENT: Anderson, ELLEN
ROBERT WEITZEL, M.D.
12/29/95
IDENTIFYING INFORMATION
This is a 91 year old widowed white female who is a resident at Pioneer Care Center in Brigham City.
CHIEF COMPLAINT
The patient is unable to verbalize. The family reports that she has been demented for some time and has recently been severely anxious.
HISTORY
The patient has had the diagnosis of dementia for 4 years. She has been suffering severe anxiety attacks of late. She had a severe hip fracture in June, 1995, and has been in rehab for this. She has been at Pioneer Care Center for the past three weeks. There she has been severely anxious, calling out for her children. She has been treated there with Xanax by Dr. Harrow without much help. She is fairly demented, mumbling, can’t finish sentences, chants to herself, and is not consolable by her family. She did have a severe depression following the hip surgery. She also had a UTI on December 1st.
PAST PSYCHIATRIC HISTORY
There has been no treatment for any past psychiatric problems.
MEDICATIONS: Amitriptyline 25 mg. Q h.s., Lasix 40 mg. Q day, potassium chloride 20 mEq Q day, Nitrostat 0.4 mg. Sublingual PRN, and Ambien 5 mg. p.o. Q h.s. for sleep but apparently has not had much treatment for the anxiety or depression she is suffering. Lortab one tab Q 4-6 hrs PRN pain, Ducolax 5 mg. p.o. Q day PRN constipation. She has also been taking Benadryl for a rash and to help her sleep.
PAST MEDICAL HISTORY
As noted, she had a hip fracture in June, 1995. She had her gallbladder removed in 1994 as well as procedure on small intestine. She has apparently had a wrist and ankle fracture secondary to osteoporosis.
C O N T I N U E D ….
Anderson, ELLEN
PAGE 2 . . .
ROBERT WEITZEL, M.D.
SOCIAL HISTORY
The patient has been widowed for 28 years. She has been a teacher in grade school and has had some college. She is LDS. She does not smoke or drink.
FAMILY HISTORY
Negative.
Alcohol and drug history are negative.
PATIENT STRENGTHS
Supportive family.
PATIENT LIMITATIONS
Dementia, multiple medical problems, and unable to respond to questions.
MENTAL STATUS EXAMINATION
She is a frail appearing white female. Speech is nonfluent and mood is very dysphoric. Affect is congruent with mood. Somewhat labile. Thought processes completely loose, thought content is difficult to ascertain. Seems to revolve around requests for family to be close. Hearing is fair. Eyesight is fair. I.Q. is untestable. Calculations, memory, abstractions, and fund of knowledge were not testable. Insight poor. Judgement poor.
DIAGNOSIS
Axis I: Major depression with psychotic features and anxiety disorder.
Axis II: Defer.
Axis III: Dementia, osteoporosis, history of hypertension and angina.
Axis IV: 3
Axis V : 22
C O N T I N U E D …
PSYCHIATRIC EVALUATION
Anderson, ELLEN
PAGE 3 …
ROBERT WEITZEL, M.D.
DISCUSSION & RECOMMENDATIONS
Initially we will continue her current medications and we will get medical workup completed. Most probably will use benzodiazepines for quick control of her anxiety and antidepressant such as Serzone or Paxil to control both anxiety and depression. Risperdal may be needed to control psychotic behavior. Also will use morphine sulfate for pain control.
ESTIMATED LENGTH OF HOSPITALIZATION
Two to three weeks.
DISCHARGE CRITERIA
Decreased depression and anxiety.
DISCHARGE PLAN
Back to Pioneer Care Center.
(Signed) Robert Weitzel, M.D.
RW/re
D: 12/30/95 12:20
T: 12/30/95 14:01
Job# 3850
PSYCHIATRIC EVALUATION
(Physicians orders)
12/30/95 Patient expired at 0855 this
a.m. Please see progress notes
Signed: Robert Weitzel, M.D.
(Physicians notes)
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12/30/95 |
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Patient died this morning at 0855. She had
erratic breathing and irregular pulse. EKG on admit showed sinus
tachycardia with arrthymia. Assessment - probable
myocardial infarction, recommend autopsy. Plan - will release to
family. Robert Weitzel, M.D. |
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DAVIS HOSPITAL & MEDICAL CENTER
DISCHARGE SUMMARY
PATIENT: Anderson, ELLEN
R. Weitzel, M.D.
ADM: 12-29-95
DIS: 12-30-95
HISTORY
The patient was admitted for treatment of intractable anxiety and severe depression. She initially had been quite demented.
HOSPITAL COURSE
On admission she was continued on Amitriptyline 25 mg p.o. q. h.s.; Lasix 40 mg p.o. q. day; potassium chloride 20 mEq q. day; Nitrostat 0.4 mg sublingual p.r.n. Trazodone 150 mg p.o. q. h.s. was started and she was given Tylenol, Mylanta, and Milk of Magnesia p.r.n. She was given Morphine sulfate 10 mg IM as a now ordered at approximately 2130.
On admission her EKG revealed sinus tachycardia with marked sinus arrhythmia, low voltage QRS and T wave abnormalities. She did not get other laboratories drawn.
She was quite agitated on admission. She settled down with the MS and Trazodone. Approximately 3:00 in the morning she became agitated again and was given another 10 mg of IM morphine. Later in the night her breathing became very erratic and then converted to Cheyne-Stokes respirations. At 3:30 she was given another 10 mg of MS IM. She slept after this. Respirations did remain erratic.
At 7:30 the nurse was unable to get a blood pressure, pulse was at 50. The patient was unresponsive. At 8:55 the patient ceased breathing and she was noted to have no pulse.
Her family was notified, and I have met with them this morning. She will be released to the mortuary immediately for funeral services.
FINAL DIAGNOSES
AXIS I: Major depression with psychotic features, anxiety disorder, NOS.
DISCHARGE SUMMARY
Anderson, ELLEN
Continued…pg 2
R. Weitzel, M.D.
AXIS II: Deferred.
AXIS III: History of angina, hypertension, osteoporosis, hip fracture, dementia.
(Signed) R. Weitzel, M.D.
RW/TL414
D: 12-30-95
T: 1-03-96
JOB #3851
ZDSAMDE1/RW-
