Post on 28-Dec-2015
Case based learning: ACP
Dr Rhian Simpson
Consultant Community Geriatrician
Cambridgeshire Community Services
Case presentation
• PN Male 01/07/19• 16/9/09: Admitted to community hospital bed from home• Discharged 2/52 previously from acute unit • Bilateral cellulitis/Poor mobility
– CCF (echo 2008 poor LV function)– AF– Type 2 diabetes– Pagets disease of the pelvis– GU 2004– Recurrent DVT (2002/2003)
Case Presentation
• Lived alone no formal support• Medication:
Flucloxacillin Digoxin 0.125 mcg
Warfarin Lisinopril 5mg
Simvastatin 40 mg calcichew D3 forte
Fexofenadine Ferrous sulphate
Bumetanide Esomeprazole
Quinine sulphate GTN
Lactulose paracetamol
Case presentation
• O/E AF 66 BP 100/60 mmHg lying• pansystolic murmur• sacral oedema JVP + 3 cm• legs: chronic venous changes• 4 areas of ulceration around ankles and forefoot• no palpable pulses• Discuss management
Case presentation
• Na 130 mmol/l, K 5.9 mmol/l, urea17 mmol/l, creatinine 155 (35 - 125 umol/l)
• HB 8.8 g/dl MCV 92• B 12, folate, ferritin normal• HbA1c 7.2 (4.9 - 6.3)• INR 2.5• ECG: AF• CXR: nil focal
Case presentation
• Management of legs• Management of anaemia• Rehabilitation
• 2/10/09: home– care package– community follow up
Case presentation
• 19/11/09: DV at home
• Gross CCF clinically
• Poor mobility, barely walking
• Medication issues: INR 4.8
• ? Retention
• Does not want to be admitted to hospital
• Had an ACP
• Discuss
Case Presentation
• District nurse found on bladder scan > 1 litre of fluid• ? What happened next
• 20/11/09: discharged home post catheter and fell and admitted into emergency respite
• 25/11/09: transferred to ward for assessment
Case presentation
• AF pulse 48 BP 90/65 mmHg• JVP to ears• bi basal creps oedema ++ legs painful
• Meds: Paracetamol, meptazinol ,digoxin, bumetanide• Discuss management
Case Presentation
• Palliative care• Oramorph regularly• 8/12/09: Cough, hoarse voice and problems with swallowing• Discuss management• 14/12/09: worsening of symptoms• 24/12/09: says he wants to die cannot bear it any longer• Discuss• 26/12/09: died peacefully on the ward