Middle-aged Patient in Dire Straits

By HENRY SCHNEIDERMAN, MD—Series Editor | May 4, 2010

Dr Schneiderman is vice-president for medical services and physician-in-chief, Hebrew Health Care, West Hartford, Conn, and president of its Connecticut Geriatric Specialty Group. He is professor of medicine (geriatrics) and associate professor of pathology, University of Connecticut Health Center in Farmington, and clinical professor, nursing, Yale University, and associate medical director, Hebrew Health Care Hospice. He is a recipient of the American Geriatrics Society Clinician of the Year award and received the Laureate award of the Connecticut chapter of the American College of Physicians.

HISTORY

A 56-year-old woman seen during physician's hospice visit. Stormy course from lupus nephritis, dialysisdependency, repeated episodes of dialysis-catheter–related peritonitis, each treated and followed by Clostridium difficile–associated disease. End-stage cardiomyopathy of mixed lupus-ischemic origin renders hemodialysis impossible. Does not wish further dialysis of any type; automatic implantable cardiac defibrillator (AICD) has been turned off. On opiates for chronic abdominal pain. Refractory but mostly morning nausea and vomiting.

PHYSICAL EXAMINATION

Intermittently lucid woman who is frequently profoundly delusional, eg, telephoning husband from hospital room to tell him she awaits him at a local department store. No abdominal tenderness or pulmonary crackles; S₃ has cleared. No mottling.

"WHAT'S YOUR DIAGNOSIS?"

Answer on Next Page

Pages: 1 2 3

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Middle-aged Patient in Dire Straits

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