History of Present Illness (HPI):
A 72-year-old Hispanic female presents to the emergency department (ED) due to a chief complaint of a fall.
She was in her usual state of health defined as living with her husband independent of all activities of daily living without limitations in functional status until the day of admission. She was talking with her daughter over the phone after eating dinner, and the patient started to feel lightheaded and sweaty and told the daughter that she didn’t feel well. The daughter immediately called EMS. EMS arrive 10 minutes later and found her confused and on the ground. Accucheck at that time revealed that her blood glucose level was 48. She received a glucagon injection and oral glucose paste with improvement in her mental status. Accucheck afterwards revealed a blood glucose level of 148. When she regained consciousness, she stated that she had right hip pain, but otherwise no complaints. She was subsequently transferred to the ED.
Past Medical History (PMH):
Diabetes Mellitus type 2 on insulin complicated by bilateral lower extremity diabetic nephropathy for the past 20 years
Hypertension was diagnosed 10 years prior
Arthritis
Past Surgical History: Cholecystectomy – 15 years ago
Allergies: No Known Drug Allergies
Family History: Husband diagnosed with prostate cancer 10 years prior and is currently diagnosed with COPD (on 2L oxygen at home) and congestive heart failure. Adult daughter and her family live approximately 15 minutes away and try to check in 1-2 times per week.
Social History: No smoking, alcohol, or recreational drug use. Dependent on daughter for transportation. Patient insurance is Medicare Advantage.
Medications prior to admission:
Aspirin 81mg po daily
Atorvastatin 40mg po daily
Metformin IR 500mg po BID
Lantus 10 units subQ daily at night
Lispro 3 units subQ with meals
Lisinopril 20mg po daily
Naproxen 500mg po BID PRN for knee pain
Physical Exam on arrival to the ED:
Vital signs:
Temperature 37.8oC, RR 16 bpm, HR 84 bpm, BP 118/68 mmHg, O2 Sat 96% on RA.
Weight = 80kg, Height = 5’5”
GEN: Elderly female, lying in a hospital bed in no acute distress
EXT: Tenderness of right hip with mild erythema, minimal swelling, and decreased range of motion due to pain
NEURO: AAOx4 with only complaints of right hip and elbow pain
All other physical exam findings are normal
Labs: Blood glucose =124, all other labs were unremarkable
Diagnostics:
X-ray of her hip and pelvis - Joint space narrowing and osteophytes of bilateral hip joints revealing severe osteoarthritis but no fracture.
Hospital Course:
She is monitored in the hospital without further episodes of hypoglycemia. Her A1c is 6.4%. Her insulin was initially dose reduced but ultimately required her home regimen of 10 units of lantus and 3 units of lispro with meals. The nurse noticed that she was frequently having difficulty feeding herself and reaching for objects. After the nurse talked to her, the patient endorsed that she has had trouble with her vision over the past year. She states that her vision has become more blurry without any pain or redness. She has not seen an eye doctor in years. She states that it has been harder to read her medication labels and thinks that she may have given herself too much insulin. The nurse notified the physician of this finding and a focused physical exam reveals that she has bilateral cataracts.
In regard to her hip pain, she continues to have pain but it has improved significantly with Tylenol 500mg q8hours.
OT Assessment:
|
Initial Evaluation – Day 2 |
|
|
ADL’s |
Set up / supervision for lower body dressing, bathing, toileting due to weakness, balance. All other areas Independent |
|
IADL’s |
Requires support for managing medications due to visual issues. Does not have an organized routine / approach at home. Has difficulty with meal preparation due to low vision and ability to reach / retrieve items. Has difficulty with bill paying due to vision but states daughter assists with this. Dependent on transportation. Reports poor sleep quality over the past 6 months, sleeping only 4-5 hours at best with naps during the day. |
|
Cognition |
MoCA – 24/26 – suggesting mild cognitive impairment possible most notably in the areas of executive function, abstraction, and delayed recall. |
|
Psychosocial |
PHQ-9 – 9 suggesting mild depression. Pt. expressed sadness / concerns / worries over declining health, not being able to care for her family like she had been able to and being more isolated at home. Reports loss of interest in prior leisure activities. Expresses worry about taking care of her spouse. |
|
Summary |
Slowly declining in ability to complete many IADL’s such as meal preparation, cooking, and leisure activities with decreased participation in most activities over the past year. Reports difficulty sleeping at night that results in daytime napping. Physical activity level is low – primarily focused on walking to the kitchen, bathroom, bedroom, and to the living room. Participates in self-care, meals, watching TV, and enjoys when her daughter visits. Role participation is limited to wife and mother. Has limited social contact beyond home / spouse / daughter. Pt. reports feeling discouraged about the future and feels emotionally exhausted most days. Expresses concerns about health, her changing role in the family, and not being able to care for others as she had in the past. |
PT Assessment:
|
Initial Evaluation Day 2 |
|
|
Manual Muscle Test |
Right Upper Extremity 5/5 Left Upper Extremity 5/5 Right Lower Extremity unable to accurately assess due to pain Left Lower Extremity 4/5 |
|
Stand Pivot Transfers |
Contact Guard Assist for safety, with increased time to complete |
|
Berg Balance Scale |
32/56 |
|
6 Minute Walk Test |
Completes 20 feet using cane and then needs to take a sitting rest break |
Patient will be discharged to home tomorrow. From your profession’s perspective, what are your recommendations including education, resources and services.
What potential collaboration with other professions should occur to facilitate a safe transition?