Caring for Junior



M1PBL C4 2007

Caring for Junior

Part I

Fred A. Roberts, 54, brought his father, Fred R. Roberts, Jr., for a new patient visit. (When Fred A. Roberts outgrew the name “Freddie”, he became “Fred” and his dad agreed to go by “Junior”. Though “Junior” is now 82 years old, the nickname stuck.)

Junior is alert and pleasant. He says, “It’s nice to see you again. You look well.” Junior is dressed nicely, yet his black dress shoes are scuffed and his blue three-piece suit fits loosely and has several scattered food stains. When asked directly, Junior offers little information about his medical history. With further questioning, he becomes annoyed and finally points to his son saying, “Ask him the questions. He’s Mr. Know-it-all.”

Fred expresses general concerns about his father’s health; including an estimated 30-pound weight loss since last year, and memory problems for about 3-4 years. Junior can recall his wartime service & name of his high school, but is often mixed up about recent events, and asks frequently about a brother who died last year. Junior quit going to Wednesday night church suppers about a year ago. Fred takes his dad to lunch and rates his dad’s appetite as “excellent.” Junior performs ADL’s by himself, but he does require assistance with bathing. He needs help with most IADL’s. He still drives and manages his medications. Junior never smoked or drank alcohol, and lives alone in an apartment, though Fred checks on him daily.

Junior denies being anxious, but complains of being tired because he gets up “too early.” Junior complains about missing his late wife and mentions he “is worth more dead than alive.”

Junior doesn’t recall his medications and Fred remembers only the three blood pressure pills (atenolol, Dyazide, and lisinopril). Despite his medications, Junior was hospitalized twice recently for hypertension and weakness. Both hospitalizations were brief and Junior was discharged on only one pill.

You ask Junior to put on a gown as you step out of the room.

M1PBL C4 2007

Caring for Junior

Part II

When you leave the room, Fred follows you out. Fred is worried about his father’s driving and will no longer ride in the car when his dad drives. Junior had an accident four weeks ago near the city center. Junior was not injured but was cited for failure to yield. Fred tells you that he’s “stressed out” dealing with his dad and may have to put him in a nursing home.

Minutes later, you re-enter the room. Junior is still fully dressed, holding the gown in his hands. Fred extends his hand to his dad and asks for his jacket, which Junior hands him. Fred asks for subsequent clothing items, one at a time, by name. Soon, Junior is undressed and gowned.

Junior is 5 feet 7 inches tall, and weighs 124 pounds. He requires help up onto the examination table. His sitting blood pressure is 178/80 (L) and 180/74 (R) and pulse is 82. His pupils are equally round and reactive to light. His extra-ocular movements are intact. On fundoscopic examination, the discs are sharp, without gross hemorrhages or exudates. The cardiovascular examination reveals has a regular carotid upstroke, a normal S1 and S2, and an S4 with a holosystolic murmur medial to the apex with radiation to the axilla made louder with handgrip. The PMI is laterally displaced. Lungs are clear. The abdominal examination is normal. You find no lymphadenpopathy. There is slight pitting edema of both lower extremities to the mid-calf. Vibratory sensation is decreased. Strength is intact throughout. Muscle stretch reflexes are present and equal, except for absent ankle jerks. He has no tremor or bradykinesia, but some rigidity. His gait is slow, a bit shuffling, with some unsteadiness in turning. His affect is flat.

Junior, who completed high school, scores 18/30 on the Folstein Mini-Mental State examination (MMSE) and 8/15 on the Geriatric Depression Scale (GDS). You order some laboratory studies. You provide Fred with a medication box and instruct him on its use. Fred provides you with a copy of Junior’s Living Will along with his Durable Power of Attorney for Healthcare that designates Fred as his proxy. You note that both were completed 5 years ago. You suggest to Fred that he should consider initiating the process for guardianship of his father.

M1PBL C4 2007

Caring for Junior

Part III

The next day Junior’s lab results return. His electrolytes are unremarkable except for his BUN of 22 with a creatinine of 1.3. Calcium, CBC, RPR, TSH, and B12 level are unremarkable as well.

In the late afternoon you receive a page from the Emergency room. The emergency physician wants to inform you about Junior, who arrived at the hospital by ambulance. She reports that Junior’s son found him down on the floor in his apartment. According to Fred, Junior looked fine the prior evening when Fred went over his house to fix Junior’s dinner and arrange his medications.

This afternoon when Fred went to check on Junior, he found his father on the floor. He had no focal weakness, but had been incontinent. When Fred tried to help his dad up to his feet, he mumbled and fell out again. Fred tried to sit Junior up, but he was less coherent sitting.

Fred called 911. His initial blood pressure by the EMS was 70/palpation with a slow, thready pulse. In the ambulance, Junior said that he did not fall, but he that he felt bad and just decided to sit down on the floor.

Fred had brought all Junior’s medicines in a bag. They included:

|Furosemide 20 mg po bid |Valium 10 mg PO qhs prn |

|Potassium chloride 16 mEq po q am |Aspirin 325 mg po daily |

|Atenolol 100 mg po q am |Tenormin 50 mg PO daily |

|Lisinopril 20 mg daily |Lasix 40 mg PO daily |

|Darvocet N-100 Q4-6 hrs prn pain |Terazosin 5 mg po QHS |

|Diazepam 5mg po qhs prn for sleep |Fosamax 35 mg po weekly |

|Oxybutynin 5 mg PO BID |Donepezil 10 mg po QHS |

|Paroxetine 20 mg daily | |

M1PBL C4 2007

Caring for Junior

Part IV

Junior’s blood pressure in the ER rose to 110/60 with fluids. His breathing is normal, with a respiratory rate of 12. Junior’s EKG shows left bundle branch block. His color looks good and without cyanosis, his conjunctiva are pink. There is no evidence of trauma. Junior has no pelvic or hip pain. His range of motion about the hip is normal. His labs show no sign of dehydration or anemia. You agree with the emergency physician, and admit Junior to the hospital to rule out a heart attack. A head CT scan shows ventricular enlargement with atrophy consistent with the patient’s age. The hospital staff pulls an EKG from 2 years previous that showed LBBB also.

On admission, Junior gets no medications for blood pressure. The next morning his blood pressure is up to 160/74. Because Junior is wandering in the halls at night he is given diphenhydramine 50 mg po for sleep and additionally receives haldol 5 mg IM stat and twice daily orally by the hospital physician.

Junior’s blood tests show that he did not have a CK (Creatine Kinase) bump or elevated troponin. Additionally, a chest x-ray and an expanded metabolic panel were normal. His telemetry monitor shows no arrhythmias.

Three days later you get an urgent call from Fred. He went to the hospital to pick up Junior, but found that he has great difficulty walking, and requires a wheelchair to get as far as the door of his room. Junior seems lethargic and a bit more confused. He doesn’t see how his father will be able to go back to his apartment alone. You page the hospital physician to discuss the situation. PT and OT are consulted, and though it takes two more days Junior is discharged to a sub-acute rehabilitation facility.

M1PBL C4 2007

Caring for Junior

Part V

Junior recovers some function, but Fred does not believe he can return home and convinces Junior to be discharged directly to an assisted living center. You talk with the physician in the Rehabilitation center and learn that Fred is now taking only atenolol 50 mg po daily; paroxitine 10 mg daily; vitamin E; donepezil 10 mg daily, and aspirin 325 mg daily.

At your follow-up visit with Junior 2 weeks later you learn that Junior had a difficult adjustment at the assisted living facility at first, sometimes shouting at other staff members and residents. After the first week though, he seemed to do better. According to Fred the facility staff enjoys Junior, and takes a personal interest in him. They note that Junior seems more confused in the morning, but does better after breakfast. The staff also reports that he has sundowning at times. Junior often complains to the staff of “being tired.” One time he told a staff member that his “life is not worth living.”

M1PBL C4 2007

Caring for Junior

Part VI

Fred suggests, and Junior agrees, to an increase in the paroxetine. Fred also provides you with documentation that he has been appointed as legal guardian for his father.

After 6 weeks of paroxetine at 20mg daily, Junior seems more interactive, but still says he’s “tired.” He participates in more group activities at the facility, and he continues to go out weekly with his son for lunch. His son says that Junior “laughs a lot more than he used to do.”

Junior’s weight increases to 130 pounds. Junior renews his interest in the cheeseburgers and chocolate malts at the city’s last remaining drive-in.

Fred becomes very involved in the local Alzheimer’s Association and is participating in a study of Pittsburgh Compound B at the local medical center.

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