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DAVIS HOSPITAL & MEDICAL CENTER

REPORT OF CONSULTATION

 

PATIENT: Alldredge, ENNIS  RM 307-01

DATE OF CONSULTATION: 1/10/96

ATTENDING PHYSICIAN: ROBERT WEITZEL, M.D.

CONSULTING PHYSICIAN: DAVID G. DIENHART, M.D.

  

REASON FOR CONSULTATION

Admission to the Geropsychiatric Unit, evaluation of medical problems.

HISTORY

Mr. Alldredge is a 83-year-old Caucasian male with a history of severe dementia admitted now to the Geropsychiatric Unit for increased agitation and combativeness, in transfer from the Sunshine Terrace Nursing Center. It is felt that he is an increase risk to other residents. His combativeness includes biting and kicking.

His medical history is remarkable for dementia. Medical note from Dr. Cunningham (4/17/95) which states the patient has clear loss of recent memory. He was unable to state the president of the United States. When he was asked at that time the similarities between a bowling ball and an orange, he stated "you could get juice out of a bowling ball." As mentioned he was felt to have senile dementia, Alzheimer’s type. In August of 1995 the patient was seen and voiced no complaints. It is noted in the examination that he was alert, lucid and responded appropriately to questions. His examination was unremarkable. On August 31st, 1995, it was noted that he was disoriented and did not know the time of year. He was unable to perform simple mathematical calculations. He was said to be sometimes confused. On October 12th, 1995, it is stated that his communication skills were disruptive and incoherent at times. On 11/16/95 it was noted and felt that he had an expressive aphasia, and seemed to understand spoken sentences to him. On 1/4/96 he was completely disoriented however awake and alert. He was unable to talk in a lucid manner. His communication was without significant meaning.

C O N T I N U E D . . .

DAVIS HOSPITAL & MEDICAL CENTER

REPORT OF CONSULTATION

 

PATIENT: Alldredge, ENNIS RM 307-01

PAGE 2 . . .

 Recent medications at Sunshine Terrace, Lente insulin injection 20 units subcutaneous q a.m., Lente insulin 5 units subcutaneous q. p.m., Risperdal 0.5mg b.i.d. (stopped 1/8/96), Pepcid 20mg daily, L-Thyroxin .1mg q. a.m., Diphenhydramine 25mg q. h.s., ___________ 1mg q. a.m., enteric coated aspirin one tablet p.o./b.i.d., Oxybutynin 5mg one p.o./b.i.d. Micro-K 10mEq daily, Cimetidine 800mg one p.o./q.j.s. (stopped 1/4/96), Hytrin 5mg one p.o./q.h.s., Restoril 15mg one p.o./q.h.s., BSS 100mg one p.o./b.i.d., Mellaril 25mg one tablet p.o./t.i.d. (stopped 12/28/95), Mellaril 50 mg t.i.d. from 18/28/85 (?) through 1-4-96 and then stopped on 1/4/96, Buspar 10mg p.o./t.i.d.

PAST HISTORY

MEDICAL HISTORY: 1) History of hypertension with coronary artery disease, status post coronary artery bypass grafting 1982. Old EKG in April of 1995 showed sinus rhythm with changes consistent with LVH, non-specific ST-T wave changes and prominent Q-waves in leads 2, 3, and AVF. EKG not seen but reported EKG in old medical record.

2) Renal insufficiency.

3) History of gastroesophageal reflux.

4) History of mycosis fungoides, end-stage. Medical record indicates patient had total body irradiation at one point.

5) History of hypothyroidism.

6) History of urinary incontinence.

MEDICATIONS: See above.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY: The patient worked at Hill AFB as a plane mechanic.

HABITS: He does not smoke or drink.

PHYSICAL EXAM

GENERAL: The patient is an elderly male, supine in bed, with Cheyne-Stokes respiration pattern with apnea periods from 20 to40 seconds.

VITAL SIGNS: Admission temperature 97 degrees, pulse 96, respirator 20 per minute, blood pressure 160/100.

C O N T I N U E D . . . REPORT OF CONSULTATION

DAVIS HOSPITAL & MEDICAL CENTER

REPORT OF CONSULTATION

 

PATIENT: Alldredge, ENNIS RM 307-01

PAGE 3 . . .

 

HEENT: PERRL, 2mm to 1mm. Tympanic membranes are dull bilaterally. Nasal mucosa is pink. The mouth is dry. There is erythema of the tongue and palate. No obvious thrush although probably early thrush with severe dry mucosa. The gag reflex is poor.

LUNGS: Diminished breath sounds. There are no wheezes, no rales.

HEART: Regular.

ABDOMEN: Soft, non-tender. There is no hepatosplenomegaly.

GENITALIA: Small, atrophic testicles bilaterally.

RECTAL: Brown stool, hemoccult is pending.

EXTREMITIES: No edema.

DIAGNOSTIC STUDIES

Past laboratory on 10/13/95 – creatinine 1.6, BUN 18, potassium 3.9, serum protein 6.8,albumin 4.1, alkaline phosphatase 58, GGT 20, LDH 214, AST 22, ALT 19, serum iron is 100. WBCs 8000, hematocrit 44.1, platelet count 187,0000. Urinalysis unremarkable. Glycosylated hemoglobin 11.8 on 11/16/95 and 12/4 on 1/5/96. Current laboratory on 1/20/96 – sodium 146, potassium 3.7, chloride 113, CO2 28, anion gap is 5, glucose 162, BUN 18, creatinine 1.3, calcium 9.6, uric acid 6.2, cholesterol 188, triglycerides 75,total protein 6.3, albumin 3.6, total bilirubin 0.7, alkaline phosphatase 61, GGT 18, ALT 15, AST 24, LDH 207, phosphorous 2.6, magnesium 2.1, iron 47, T3 29.6, T4 6.7, T7 1.98. WBC 8500, hematocrit 43.9, platelet count 205,000, MCV 89.5. EKG shows normal sinus rhythm at 89 beats per minute, first degree AV block, prominent Q-waves in 2, 3, and AVF. Non-specific ST-T wave changes, voltage criteria for left ventricular hypertrophy. Chest x-ray pending.

IMPRESSION

  1. Severe dementia with recent increased combativeness, agitation of unclear etiology.
  2. Atherosclerotic cardiovascular disease, status post coronary artery bypass grafting 1982.
  3. History of hypertension, on Hytrin therapy.
  4. Diabetes mellitus, on insulin.

C O N T I N U E D . . .

REPORT OF CONSULTATION

DAVIS HOSPITAL & MEDICAL CENTER

REPORT OF CONSULTATION

 

PATIENT: Alldredge, ENNIS RM 307-01

PAGE 4 . . .

  1. Renal insufficiency, fairly stable by reports from October 1995.
  2. History of gastroesophageal reflux disease, unclear past definitions.
  3. History of mycosis fungoides, unknown stage, status post therapy with total body radiation.
  4. History of hypothyroidism, on thyroid replacement and current T4, T7 within normal range; pending TSH
  5. Urinary incontinence.
  6. Decrease anal sphincter tone.
  7. Probably early oral thrush.

RECOMMENDATIONS

  1. Agree with screening laboratories as performed.
  2. Straight catheterized urinalysis to obtain urinalysis and culture and sensitivity.
  3. Advise aspiration precautions with the patient’s diminished mental status and diminished gag reflex.
  4. Consider oxygen saturation for an interval of time during his periodic breathing. Suspect he may desaturate with his apneic spells. His current observed breathing pattern may be secondary to his recent significant sedation. It may suggest a component of central nervous system dysfunction as well.

Thanks for asking me to evaluate Mr. Alldredge

  

(Signed) David G. Dienhart, M.D.

 

DGD/rn

D: 01/10/96 21:19

T: 01/10/96 22:38

JOB #5734

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