Older Surgical Patient Case: Part of the Reynolds Aging Theme Curriculum

1. Older Surgical Patient Case: Part of the Reynolds Aging Theme Curriculum Amy Corcoran, MD CMD Rachel Kelz, MD MSCE

2. Goal The purpose of this educational initiative is to reach all of the medical students during their surgery clerkship to ensure a baseline of knowledge, skill, and attitude for caring for the older surgical patient.

3. Objectives • To appreciate the unique problems of the increasing number of older adult patients undergoing abdominal surgery • To characterize the medical and surgical causes of acute abdominal pain in the older adult patient • To discuss the approach to an older adult patient with an acute abdomen

4. Objectives (cont) • To appreciate the complex decision-making and rationale for the management options for an older adult surgical patient (i.e. emergent surgery, serial abdominal exams, and non-operative management) • To recognize the peri-operative complications common in the older adult surgical patient • To recognize different sites of care for older adults to recover after surgery

5. Case 78 year-old gentleman with significant PMH of diabetes and BPH who presents to his primary care provider clinic at the Veterans Administration with “upset stomach”. His primary physician is concerned and sends him to the walk-in surgical clinic for further evaluation. He complains of vague abdominal pain since last night, after going out to dinner with his wife.

6. Case continued… PMH/PSH: NIDDM BPH HTN Anxiety s/p appendectomy SH: Married 45 years, 2 children, retired carpenter, h/o tobacco, no ETOH Allergies: NKDA Medications: Metoprolol 50mg twice daily Glyburide 5mg daily Tamsulosin ER 0.4mg daily Lorazepam 1mg every 4-6hours as needed for anxiety

7. Case continued… His wife is present and reports he was doing okay until this happened. He even drove them to the VA today. He has not felt like eating and has had several episodes of small volume bilious emesis. He had one episode of diarrhea yesterday and continues to pass flatus. He is afebrile with normal vital signs.

8. 1.What are some of the challenges in assessing an older adult with abdominal pain?

9. Case continued… As you are getting ready to enter the room to examine your patient, he vomits a large volume brown and green fluid. Initially his vitals are “stable”, but upon repeating, you find that his BP is 80/50 and HR120s.

10. 2.What elements of the history and physical examination are essential for this older adult with abdominal pain?

11. Case continued… His abdominal exam reveals tympany and diffuse tenderness to percussion with guarding in the left lower quadrant only. He is alert and attentive, but understandably anxious about his condition.

12. 3. What is the differential diagnosis for acute abdomen in an OLDER ADULT?

13. Case continued… His lab results are significant for the following: WBC 8, – Hbg 10, Na 127, K 6, BUN 40, SCr 1.8, albumin 3.8

14. Case continued… You send him to the emergency department where he is fluid resuscitated. In addition, a nasogastric tube is placed which yields 1500cc of brown coffee-ground material. You fluid resuscitate him and his hbg drops to 8, however his vitals are now stable and he is mentating.

15. 4. How would you read this film?

16. INSERT FILM HERE

17. Case continued… A CT scan completed shows no passage of contrast into the large bowel. The patient and family discuss with the surgical team about an exploratory laparotomy.

18. 5. What are the factors that go into the patient-clinician discussion and decision to perform surgery in the OLDER adult?

19. Case continued… Your patient is highly functional. Both he and his family agree to surgery. The surgery finds adhesions that have caused the complete SBO – likely from a prior appendectomy. On post-op day 1 he becomes confused and pulls out one of his IVs.

20. Case continued… On post-op day 2 he unable to get out of bed to a chair. He is not eating well and you are concerned.

21. 6. What are some of the peri-operative complications or hospital risks for the older adult surgical patients?

22. Case continued… On post-op day 5 he is able to get out of bed to a chair, but is very weak and needs assistance. The family is asking what the next steps are.

23. 7.What are some of the discharge options for your older adult surgical patient?

24. Case continued… He is discharged to a nursing home for rehabilitation for deconditioning. You see him in the office 2 weeks later for his post-op visit and he is doing well with plans to return home soon.

25. 8. What key point(s) will you take home after reviewing this problem-based learning case?

26. Reference • McGory ML, Kao KK, Shekelle PG, Rubenstein LZ, Leonardi MJ, Parikh JA, Fink A, Ko CY. Developing quality indicators for elderly surgical patients. Ann Surg. 2009 Aug;250(2):338-47. • Caesar, R. Acute geriatric abdomen. In The Textbook of primary and acute care medicine, part vi: gastrointestinal disease (Bosker G, ed) Thomson American Health Consultants, 2004. • van Geloven AA, et al. Hospital admissions of patients aged over 80 with acute abdominal complaints. Eur J Surg 2000;166:866-871. • Hustey FM et al. The use of abdominal computed tomography in older Ed patients with acute abdominal pain. Am J Emerg Med 2005;23:259-265. • Kiser KW, Vassar MJ. Emergency department diagnosis of abdominal disorders in the elderly. Am J Emerg Med 1998;16:357-362. • Podnos et al. Intra-abdominal sepsis in elderly persons. Clin Infect Dis 2002; 35:62-68 • Appelbaum, Paul. Assessment of Patients’ Competence to Consent to Treatment. N Engl J Med 2007;357:1834-40.