Chronochart

Ennis Alldredge            PHOTO>>

Brief History and Hospital Course

This 82 year old married white male had had fairly rapid decline in mental status thought to be due to multi-infarct dementia, rule/out Alzheimer’s. He had a twenty year history of IDDM, long history of hypertension with CAD, S/P CABG 10 years prior, renal insufficiency, and end stage mycoses fungoides  previously treated with total body irradiation. He had been at Sunshine Terrace Nursing Center, but had recently become highly agitated and aggressive; hitting, scratching, kicking; he threw a wheelchair and fractured the hip of another (female) resident there. Ativan 3 mg. twice did little to calm him, and the nursing home was unable to contain him; he was transferred to Davis Hospital.

On admission Mr. Alldredge proved extremely difficult as he was still quite strong for his age, and frequently hurt the nurses. He was continued on insulin, Pepcid, L-thyroxine, Bumex, Micro-K, Hytrin, Oxybutynin, and ASA, and started on Risperdol 1mg. tid, Buspar 10 mg. tid and trazodone 100 mg.qhs. Because he frequently refused oral medication, and was extremely combative, a danger to himself and others, he received Haldol 10 mg. and Ativan 1 mg. IM as now and prn orders; he remained intermittently quite agitated until late on the fourth hospital day.

MRI on the third day of admission revealed what appeared to radiology to be a new left occipital infarct. He was also pyuric and dehydrated at this point. An IV was started for hydration, as the patient would not swallow fluids or medication.

On the fourth hospital day a family conference was held; the wife was called. The CVA was described and the family told that an occipital stroke might cause blindness. The situation with the patient’s refusal to swallow and diabetes necessitating IV fluid was discussed. In view of the patient’s rather clear and compelling Living Will of July, 1993, (which precluded IV) his family was offered withdrawal of interventions and comfort care, versus transfer to ICU. His family elected to withdraw care, and the IV and all previous medications were discontinued; instead the patient received regular doses of morphine 10 mg. IM q3hrs (due to patient "grimacing" and "moaning")  and Ativan 0.5 mg. q3hrs until he died the next day.

LIVING WILL

OF

Ennis Alldredge

I, ENNIS Alldredge, a resident of the Town of Oak City, County of Millard, State of Utah, being of sound and disposing mind, memory and understanding, do hereby willfully and voluntarily make, publish and declare this to be my LIVING WILL, making known my desire that my life shall not be artificially prolonged under the circumstances set forth below, and do hereby declare:

1. This instrument is directed to my family, my physician(s), my attorney, my clergyman, any medical facility in whose care I happen to be, and to any individual who may become responsible for my health, welfare or affairs.

2. Death is as much a reality as birth, growth, maturity and old age. It is the one certainty of life. Let this statement stand as an expression of my wishes now that I am still of sound mind, for the time when I may no longer take part in decisions for my own future.

3. If at any time I should have a terminal condition and my attending physician has determined that there can be no recovery from such condition and my death is imminent, where the application of life-prolonging procedures and "heroic measures" would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally. I do not fear death itself as much as the indignities of deterioration, dependence and hopeless pain. I therefore ask that medication be mercifully administered to me and that any medical procedures be performed on me which are deemed necessary to provide me with comfort, care or to alleviate pain.

4. In the absence of my ability to give directions regarding the use of such life-prolonging procedures, it is my intention that this declaration shall be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences for such refusal.

5. In the event that I am diagnosed as comatose, incompetent, or otherwise mentally or physically incapable of communication, I appoint Bradley Alldredge, and Myrna A. Gromwald (respectively and individually in that order) to make binding decisions concerning my medical treatment.

6. I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration. I hope you, who care for me, will feel morally bound to follow its mandate. I recognize that this appears to place a heavy responsibility upon you, but it is with the intention of relieving you of such responsibility and of placing it upon myself, in accordance with my strong convictions, that this statement is made.

IN WITNESS WHEREOF, I have hereunto subscribed my name at Oak City, Utah this 30^th day of July, 1993, in the presence of the subscribing witnesses whom I have requested to become attesting witnesses hereto.

(Signed) Ennis Alldredge

The declarant, ENNIS Alldredge is known to me and I believe him to be of sound mind.

(Signed) Betty Jeffrey                      Delta, Utah

Witness                                           Address

(Signed) Nancy Oppenheim             Delta, Utah

Witness                                           Address

STATE OF UTAH )

: ss:

COUNTY OF MILLARD )

 Subscribed, sworn to and acknowledge before me by ENNIS Alldredge, the

declarant, and subscribed and sworn to before me by

(Signed) Nancy Oppenheimer and (Signed) Betty Jeffery ,

witnesses, this 30^th day of July, A.D. 1993.

(Signed) Claudia Terrell

[Notary Public Seal] Notary Public

 Copies of this instrument have been given to:

 Receipt and acknowledged (Name, Address & date):

(Signed) Bradley Alldredge

(Signed) Myrna Gromwald

Ennis Alldredge  Phone Intake Data

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DAVIS HOSPITAL & MEDICAL CENTER

PSYCHIATRIC EVALUATION

PATIENT: Alldredge, Ennis

Robert A. Weitzel, M.D.

1/10/96

IDENTIFYING INFORMATION

This is a 82-year-old, married white male who has been living at the Sunshine Terrace Nursing home.

CHIEF COMPLAINT

"Who are you."

HISTORY

The patient has recently become very aggressive and combative, hitting and kicking people. He had to be restrained in a geri-chair. He has had dementia diagnosis for some time, but only recently has become a risk to himself and other residents and staff. He does exhibit sun-downing. Ativan up to 3 mg IM times 2 has been tried, but has often not been helpful. He also has been prescribed Risperdal ½ mg and a 1 mg b.i.d., but this has not been helpful. He has been having negative incidents daily. I spoke with Dr. Cunningham in Logan yesterday and approved admission. I was not informed that he is non-ambulatory before the admission.

PAST PSYCHIATRIC HISTORY

Negative.

PAST MEDICAL HISTORY

He had a hernia repair in 1990. He apparently has had a CABG. He has been a diabetic since the 1970s. He is on fairly high doses of insulin, i.e. lente 20 units q a.m. and 5 units q p.m. He is on Pepcid 20 mg q day. He was on Risperdal and that has been increased here. He had been on Benadryl for sleep and this has been changed to Trazodone here. He has been on Bumex 1 mg q a.m., aspirin 325 mg b.i.d., Oxybutynin 5 mg po b.i.d., Micro-K 10 mEq q day, Hytrin 5 mg q hs, DSS 100 mg po b.i.d., and Buspar 10 mg po t.i.d. Basically his latest labs which were faxed to us appear to show no major abnormalities.

continued…..

PSYCHIATRIC EVALUATION

ALLDREDGE, Ennis

continued…pg2

Robert A. Weitzel, M.D.

SOCIAL HISTORY

The patient is married, but he is in a nursing home. His wife does not live there, of course.

FAMILY HISTORY

Negative for psychiatric disorder.

SUBSTANCE USE: Alcohol and drug history are negative.

PATIENT STRENGTHS

None that I am aware of.

PATIENT LIMITATIONS

Dementia, combative behavior, multiple medical illnesses.

MENTAL STATUS EXAMINATION

In general, he is an elderly appearing white male who is agitated and difficult to control. Speech – he has some slurring. Mood is quite dysphoric. Affect – congruent and labile. Thought process – quite loose and exhibits blocking. Thought content – difficult to ascertain secondary to patient being uncooperative. Perceptions – hearing and vision seem adequate. Cognition – IQ seems grossly impaired. Calculations not tested. Memory is very poor, obviously, but he will not cooperate with testing. Abstractions – not tested. Fund of knowledge – not tested. Insight – poor. Judgement – poor.

DIAGNOSIS

Axis I: Psychosis NOS.

Axis II: Defer.

Axis III: Dementia, history of dyspepsia, possible peptic ulcer disease treated with Pepcid. Hypertension treated with Bumetanide and Hytrin. Hyperthyroid treated with L-thyroxin. Constipation treated with Docusate sodium.

Axis IV: 4.

Axis V: 22.

continued….

PSYCHIATRIC EVALUATION

ALLDREDGE, Ennis

continued…pg3

Robert A. Weitzel, M.D.

DISCUSSION & RECOMMENDATIONS

We will quickly control his psychotic behavior with some IM Haldol and Ativan. He has currently received these and is doing well. I would like to have him on a higher dose of Risperdal. I will continue the Buspar. He will probably be started on Depakene as needed and he will have prn Ativan and Haldol.

ESTIMATED LENGTH OF HOSPITALIZATION

2 to 3 weeks.

DISCHARGE CRITERIA

No combativeness.

DISCHARGE PLAN

Back to Sunshine Terrace.

(Signed) Robert A. Weitzel, M.D.

 RAW/kl

D: 1/10/96 16:25

T: 1/10/96 16:39

Job # 5699

1/10/96 9 p.m. 
Glycerin swish and swallow mouth four times a day Nystatin swab mouth 5 times a day for 7 days
Straight catheter urinalysis and culture and sensitivity if indicated.
Hemocult stool 
Oxygen saturation (indecipherable) during periodic breathing
Head of bed elevated 20 degrees all times as feasible. 
Signed D. Dienhart, M.D.
1/10/96 Noted B. Hardy, RN 2210

Ennis Alldredge   UA

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 31^st, 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 12^th, 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 .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 . . .

5. Renal insufficiency, fairly stable by reports from October 1995.
6. History of gastroesophageal reflux disease, unclear past definitions.
7. History of mycosis fungoides, unknown stage, status post therapy with total body radiation.
8. History of hypothyroidism, on thyroid replacement and current T4, T7 within normal range; pending TSH
9. Urinary incontinence.
10. Decrease anal sphincter tone.
11. 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.