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