The case: To ER or not to ER?

As I puttered around my house one Saturday morning, my pager went off. “Dr. Kernisan? This is Tina from the nursing home. We’re calling you about Mrs. F. She’s 78 and has a diagnosis of advanced lymphoma. She’s been anemic and just got a blood transfusion again a few days ago. She’s now very weak, pale, and her blood pressure is low. Her poop looks red.”

Although by then I had fired up my computer and was remotely logging in to Mrs. F’s chart, this sounded like a no-brainer. I didn’t know Mrs. F personally, but that weekend I was on call by phone for our medical group’s nursing home. From the brief description, Mrs. F sounded critically ill, and was probably bleeding internally. She needed hospitalization ASAP.

“But she says she doesn’t want to go to the ER,” the nurse continued...  Read more

The case: a pesky, common sore

Mr. G, an always-cheerful 85-year-old former Naval officer, came in complaining one day of a painful ulcer on his inner shin. It's a common complication for someone who has poor circulation in the leg veins (also known as “venous insufficiency”), which is a frequent cause of chronic lower leg swelling. Our clinic nurses did their best to help it heal by setting Mr. G up with good compression stockings, appropriate wound dressings, and scheduled nursing appointments for wound care every other week.

Two months later, Mr. G came in for a follow-up visit with me. Venous insufficiency ulcers often take weeks or even months to completely heal. However, I was surprised to see that not only was the ulcer still there, but despite the hard work of our nurses, it had hardly improved at all. How could this be?

The challenge: A downside of multiple...  Read more

The case: A preventive pill goes unswallowed

“Doctor, he won’t take his blood pressure meds,” Mr. B’s son said, sighing and looking exasperated. Internally, I sighed too, wishing things could be easier for this man whose 82-year-old father had mild Alzheimer’s dementia.

Among the many challenges of assisting a loved one whose mind is slowly slipping, coping with frequent refusals to take recommended medications seems to be among the most common -- and most frustrating.

In Mr. B’s case, I hadn’t prescribed much: just one blood pressure pill. My patient for years, Mr. B has always preferred to take as few medications as possible. But after a minor stroke a few years before, he still had very high blood pressure, and these facts substantially raised his risk for another stroke. Like most geriatricians, I usually focus on avoiding disability...  Read more

The case: An ER mystery

My patient, 85-year-old Mr. C. -- a tall, courtly gentleman who always reminds me of a late-model Peter O'Toole -- sat down short of his easy chair at home and fell. Within minutes, his daughter found him on the floor. She helped him to the chair, and they watched some TV. But half an hour later, he was unable to get up again and walk. She took him to the emergency room for evaluation.

"I'm fine. Nothing hurts," Mr. C. told the busy ER staff more than once. "I just want to go home." X-rays of his hips and pelvis revealed nothing, and so -- after an exam that probably lasted only a minute or two -- he was discharged.

Back home, however, he still couldn't walk. He still insisted nothing hurt. “I’m a tough old bird,” he told his daughter. Later that night, though, she noticed that he grimaced every time he rolled over in bed. She knew something was wrong...  Read more

The case: An incomplete health assessment

I met Mr. D, 93, during a hospitalization for treatment of clots in his deep leg veins. Like many who live into their 90s, he also had a history of heart disease well documented in his charts. As the team was preparing to discharge him, the medical resident noted that Mr. D’s blood pressure in the hospital had been 140/80. Since conventional guidelines recommend a blood pressure lower than 130/80 for people with heart disease, the resident recommended that Mr. D’s blood pressure medication be increased.

That's when I realized she’d overlooked two factors in the patient's history:

1) Mr. D had a history of recent falls in the home. In the elderly, blood pressure medicines sometimes work too well; if the blood pressure gets too low the person can feel lightheaded, or fall.

2) Mr. D also had mild-to-moderate dementia, which probably was Alzheimer’s...  Read more