GM is a 90 year old widow who lives alone in a studio apartment in a senior housing building.

Past Medical History

coronary artery disease: balloon angioplasty 12/97
biliary obstruction due to stone impacted in common bile duct: ERCP and transhepatic
     choledocal lithotomy/ultrasound stone disintegration 9/98
depression, recent onset
mild systolic hypertension, many years
degenerative osteoarthritis: left knee replacement 10/93
urinary frequency and nocturia, 3 years
hypothyroidism, many years
glaucoma, many years
bilateral cataracts: lens implants 1986 and 1991
appendicitis with perforation and intraperitoneal abscess: surgical drainage 1985

Medications:

metopralol 12.5 mg BID
HCTZ 25 mg 3 times/week
thyroxine 75 mcg daily
ASA 325 mg daily
Timolol eye drops 2 each eye BID

     Following discharge from the hospital in October, 1998, she was stable and depression which had worsened during the period of hospitalization had improved in association with a course of Ritalin treatment for 3 months. In April, 1999, she began to note increased fatigue, new onset of shortness of breath and lightheadedness on standing. These symptoms progressed over a period of 3 days and because of a marked increase in lightheadedness, she activated the Medic Alert pendant which she wore around her neck. In response, an EMS ambulance crew was sent to her apartment where she was found to be alert but dyspneic and unable to get up from bed. Examination revealed marked bradycardia of 20/minute and blood pressure 80/60. A cardiac monitor was attached and she was taken immediately by ambulance to the hospital where she arrived in the Emergency Department approximately 10 minutes later. Over the next 2 to 3 minutes she developed complete asystole necessitating immediate endotracheal intubation and insertion of a temporary transvenous pacemaker which resulted in the restoration of a sinus rhythm and return of blood pressure to 135/75. She was subsequently transferred to the coronary care unit with the pacemaker functioning, on a respirator and sedated with intravenous doses of Versed. A Foley catheter was inserted in the bladder. Wrist restraints were applied because of attempts to pull on the ventilator tubing.

     On the next day, a permanent dual chamber pacemaker was implanted and the patient was returned to the CCU, continuing on the respirator and with Versed sedation. On the following day, extubation was attempted but was unsuccessful because of severe laryngeal edema. The endotracheal tube was reinserted and she was started on IV dexamethasone 4 mg every 6 hours. Versed was continued for sedation. A nasogastric tube was placed and tube feeding was begun to maintain nutritional support. After 4 days of dexamethasone, the endotracheal tube was successfully removed. The dexamethasone was then tapered and stopped 5 days later. The nasogastric tube was removed and oral feeding was started with a thickened liquids dysphagia diet. The Foley catheter was removed but she was unable to void and on straight catheterization had a residual urine volume of 500 ml. Urine was positive for WBCs and bacteria and treatment for urinary tract infection was started with Bactrim. Hematocrit which had been 38% on admission fell progressively to 27% during the 9 days spent in the CCU. Marked confusion was evident after the endotracheal tube was removed and gradually became less apparent.

     After the extubation, attempt at ambulation was begun. Initially, she required 2 persons to assist in getting from bed to chair, but over several days could transfer from bed to chair with one person assist. At this point, she was transferred to the Rehabilitation Medicine Service where she received intensive physical therapy for 3 hours per day for the next 2 weeks. By this time, she was able to transfer from bed to chair to bathroom independently and to walk 120 feet with use of a walker. Her diet progressed from dysphagia to regular with no problem. Mild confusion and difficulty following directions were persistent. She continued to have urinary frequency but urinalysis and culture were negative.

     She was discharged to return to her apartment with arrangements made for a live-in personal care aide for 14 hours daily from 6 pm to 8 am. She continued to progress so that after 10 days back in her apartment she not longer required the services of the aide. At the present time, major complaints are easy fatigue and nocturnal urinary frequency. She continues to have difficulty following directions.