Case: Part Three
Mr. Lee's physical exam reveals mild cogwheeling, increased upper limb tone, a coarse tremor, and some pedal edema. His JVP is elevated at 5cm above the sternal angle with a positive hepatojugular reflux sign (palpation of the liver leading to a sustained rise in the JVP). There is diffuse, smooth and non-tender liver enlargement on palpation.
His current medications in hospital are:
- Haloperidol 1-2 mg. prn
- Benzotropine 05.-1 mg. prn
- Morphine 2-5 mg. prn
He is also prescribed:
- Hydrochlorthiazide 25mg o.d
- Digoxin 0.25mg o.d.
- Enalapril 5mg o.d.
- Metoprolol 25mg bid
- Cimetidine 300mg bid
- Ditropan 5mg bid
- Glyburide 5mg bid
- Nitroglycerin 0.3 mg sublingual prn
Lab investigations today show:
- B12 = 154 (200-600)
- TSH = 3.2 (0.34-4.82)
- Mg = 0.5 (0.7-1.1)
- Troponin < 0.06, INR = 2.2 (0.9-1.2)
- Digoxin Level = 2.1 (1.0-2.5)
- Amylase = 57 (35-90)
- AST = 47 (10-38)
- ALT = 72 (20-65)
- Bilirubin = 9 (0-18)
- alk phos = 86 (50-200)
- gGT = 84 (10-55)
- albumin = 22 (34-50)
- Ca = 2.17 (2.00-2.55)
- glucometers ranging from 2.7-11.8
The bloodwork shows B12 deficiency, low albumin suggestive of malnutrition, low magnesium level, and mildly elevated liver enzymes. There is also quite a fluctuation in the sugars.
A chest X-ray shows cardiomegaly with pulmonary re-distribution, suggestive of congestive heart failure. Urinanalysis shows no WBC’s or nitrites. Urine and blood cultures are drawn but later prove to be negative.
The social worker is able to contact his son, who has returned and tells you Mr. Lee’s alcohol intake has averaged 6-8oz. of hard liquor daily over the past 7 years since his wife left him due to his previous spousal infidelity and alcohol binges. Mr. Lee was born and raised in Southern China, and fought in the civil war for the Kuomintang against the Communists. He was taken prisoner by the Communists, incarcerated, but was later freed by his fellow soldiers.
Mr. Lee subsequently fled to Taiwan in the mass exodus of 1949, and studied electrical engineering and later business administration. He immigrated to Canada in 1972, but continued to travel frequently to Asia for business (and romantic) reasons until he retired four years ago due to ill health.
After an attempted home invasion one year ago, Mr. Lee was diagnosed with depression and anxiety but refused to see a psychiatrist. The pharmacist’s Pharmanet search shows that Mr. Lee's family physician prescribed paroxetine 30mg daily (for treatment of depression) and lorazapam 1-2mg at bedtime as needed over the past four months.
The son doubts that Mr. Lee's family doctor knows about his drinking pattern as he is quite secretive about it, and empty bottles are usually hidden away at home.
Mr. Lee is generally independent with both activities of daily living (ADLs) and instrumental activities of daily living (IADLs), and his son helps him with buying groceries and also takes him to the bank. He expresses being lonely and stays at home otherwise. The son says Mr. Lee is somewhat hard of hearing and usually wears a hearing aide.
Mr. Lee's son is upset that his father can no longer recognize him since the admission.