1. May 2003 Geriatric Presentation Toby Andrew Hampton, M.D.

2. Patient ID 75 y.o. White male Veteran admitted to VAMC Mountain Home Nursing Home on 5/12/2003

3. Chief Complaint and HPI CC: Weakness, Falls, Hallucinations Pt. Has Parkinson’s disease and has had hallucinations since starting Sinemet. Recent addition of Seroquel has not alleviated hallucinations. Pt. Also c/o recent increase in weakness and falls about 1X q day.

4. HPI Continued Pt. Had been living at home with his wife but due to the increase in weakness and falls, the wife is no longer able to care for him. He is admitted to NH here for med adjustment and for PT to increase strength and endurance. Dizziness worse with Seroquel

5. PMH Coronary artery bypass times 4 on 5/30/1996 Peptic Ulcer Disease Ocular histoplasmosis dx in 1980, legally blind Degenerative joint disease, Arthritis HTN Hyperlipidemia Phlebitis of superficial vessels in lower extremity

6. PMH Continued Sensorineural Hearing Loss Shy-Drager Syndrome Benign Prostate Hypertrophy Chronic Constipation Parkinson’s Disease

7. Other Hx: Social hx: Lives at home with wife until admission, No alcohol, No tobacco for the past 20 years, No illegal drugs. Has 3 children Fam. Hx: Pt. Can’t recall any illnesses is the family.

8. Current Meds on Admission Aspirin Tylenol Sinemet Fluocinolone Latanoprost Daily Multivitamin PRN Nitroglycerin SL

9. Meds Continued Nitroglycerin patch Pramipexole Seroquel Ranitidine Simvastatin Sorbitol and Mag Citrate prn Allergic to Pcn and IVP dye

10. Review of Systems 20 lb weight loss over past 6 months Dry eyes Cough each am with brown sputum Constipation Some night-time incontinence Arthritic pain in hands, knees, and hips + Hallucinations, No depression

11. Physical exam Vital signs Wt. 181.7 lb Temp: 95.3 Pulse: L-70; SI-70; St-78 Resp: 18 BP: L-133/65; SI-119/70; St-94/55

12. Physical Exam General: alert, oriented to person and place, but not to time; resting tremor HEENT: masked facies, missing two molars, TM’s occluded by cerumen Neck: No thyromegaly, No carotid bruit CV: RRR, no m,r,g; Chest- gynecomastia Lungs: CTAB Abd: Soft, +BS, NT, ND

13. Physical Exam Extremities: no c/c/e, UE muscle strength 5/5 bilat. And LE 4/5 stength bilat.; DTR’s UE and LE 1+ bilat. Neuro- CN 3-12 intact. CN 2 affected by near blindness. Gait very unsteady. Monofilament exam reveals sensory deficit to ankles bilat. Proprioception of toes and foot is intact bilat. Skin-Mult. bruises

14. Misc. MMSE- 26/30 Geriatric Depression Scale 2/30 Pt. Does need assistance with his ADL’s and cannot perform any IADL’s Pt.’s wife states hat their inances are holding OK for now.

15. Pertinent Lab DATA 5/12/03: UA-WNL; INR 1.25; BMP- WNL; Total Chol-140; WBC 7.3; HGB 14.7; HCT 42.5; PLT 188 4/23/03: NH3 <0.9, FOLATE 317; RPR- nonreactive; TSH-2.2; VIT B12-749

16. Nursing Home Course Pt. Tolerating PT quite well. Seroquel discontinued. Geodon 20 mg po bid started with a decrease in hallucinations per pt. Pt. Still suffering from night-time incontinence. Falls decreased to 1 q 2-3 days.

17. Assessment and Plan 1. Parkinson’s (Possible Shy Drager)- Cont. Sinemet and pramipexole. 2. Hallucinations- Cont. Geodon and Geropsych is following. 3. Weakness- Cont. PT 4. Orthostatic Hypotension- monitor fluid intake and advise pt. To hold on to something as he stands up slowly to decrease orthostasis.

18. Assessment and Plan 5. Night-time incontinence- restrict fluids after 8 pm 6. Constipation- Cont. prn sorbitol and Mag Citrate 7. Falls- Likely multifactorial including Parkinson’s, orthostatic hypotension, poor sensation in feet, weakness, and blindness.

19. Shy-Drager Syndrome AKA:”Multiple System Atrophy”

20. Facts about Shy-Drager Prevalence of 4.4 per 100,000 10% as common as Parkinson’s Disease Avg. age of onset 54 Predominately Male>Female 75% of patients with diagnosis present with complaints related to autonomic dysfunction.

21. Autonomic Dysfunction Symptoms Urinary retention, incontinence erectile dysfunction orthostatic hypotension apnea, or inspiratory stridor snoring or loud respiration Inability to sweat Resistance to levodopa

22. Movement Presentation 25 % of patients with Shy-Drager Syndrome will present with movement symptoms related to cerebellar or striatonigral lesions. These patients show the typical autonomic symptoms within 5 years of the movement symptons. Movement symptoms of Shy-Drager are very similar as for Parkinson’s.

23. Treatment Dietary increases of salt and fluid L-Dopa may be useful in some cases sympathomimetic amines NSAIDS salt-retaining steroids alpha-adrenergic meds Sleeping in a head up position reduces am orthostatic hypotension

24. Prognosis Progressively fatal disease Death usually occurs within 7-10 years of diagnosis Death usually ensues secondary to stridor, aspiration pneumonia, or cardiac arrest.

25. The End The End