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Kornhauser Health Sciences Library

Mona Benen: The Case

Problem Based Learning guide for 1st Year medical students.

 

The Case

 

HPI:

Mona Benen is a 64-year female patient who is transported to the University Hospital emergency department at 10:15 am on a Saturday from Beltway Rehabilitation and Nursing Center. Chief complaint is severe back pain with new numbness and weakness of her legs.

She reports that this morning during her transfer from bed to wheelchair, the patient experienced severe pain in her lower back and a "crunching" feeling. She was moved back to her bed as sitting was very painful.

Past Medical History: Osteogenesis imperfecta (OI) type III. Greater than 250 bone fractures, most of which occurred during childhood and adolescence.                                                                                                                              

Medical History: Oxycodone ER 30 mg po for chronic pain.  Oxycodone 10 mg po q4-6º prn for severe pain                                                           

Family History: No previous family history of OI.  

Social History: She does not smoke, drink alcohol or use illegal drugs. Her only family is a brother and sister who live a couple of hours away. She lives in an assisted living center. 

ROS: Mona also states that prior to today she has experienced lower back pain along with intermittent and variable motor weakness and numbness in the right and/or left lower limbs over the last decade or so. She reports normal motor and sensory function of the upper limbs. 

Physical Exam:

Vitals
Test Measurement
T 99.2 F
HR 102
BP 142/88
SpO2 93% 
Height 3'7"
Weight 60 lbs

 

General:  Alert and oriented, answering questions normally, appears very uncomfortable

HEENT: Pupils reactive and equal, EOMI. Blue sclera are noted, head appears large compared to body size with triangular facies, edentulous, hearing aids

Thorax: Pectus carinatum and scoliosis with chest wall deformity noted, decreased breath sounds bilaterally

CV:  Regular rate, tachycardic, no murmurs, pulses intact in all 4 extremities, all 4 extremities equally warm and well perfused

Abdomen: Soft, nontender, bowel sounds present, no masses, exam limited by body habitus. Unable to palpate bladder.

MSK:  Multiple deformities of limbs consistent with fracture history, absence of normal bony landmarks. Severe lower back pain with any movement.

Neuro: She is incontinent of bowel and bladder with presence of stool and urine on examination. She is unaware of the sensation or of having voided and is unable to change the tone of the anal sphincter at the request of the examiner. She lacks sensation in the saddle region and extending down the back of both legs. She is diffusely weak in both legs, although exam is limited by pain. She is unable to plantarflex either foot. Babinski reflex is downgoing bilaterally.

Diagnostic evaluation:

Plain films of her hips and spine show multiple fractures and deformities from old fractures.  An MRI of her spine is then ordered (T2-weighted MRI images shown below):

MRI 1 for Benon

Benon MRI 2

Radiologist's Summary:

  • Acute compression fracture of T11 vertebral body
  • Evidence of multiple previous lower thoracic and lumbar vertebral body compression fractures
  • Severe sacral deformity involving S2 – coccyx vertebra compression fractures (S1 – coccyx has been highlighted in yellow dashed lines on sagittal image)
  • Biconcave lumbar vertebral bodies (fish vertebrae)
  • Also noted: 
  1. Thoracic levoscoliosis with mild compensatory lumbar dextroscoliosis
  2. Increased lumbar lordosis

Hospital Course:

Ms. Benen is evaluated by the neurosurgeon on call. She is advised that she is not a candidate for sine surgery given the fragility of her bones.

She is admitted to the hospital for optimization of pain control and for evaluation of her care needs as she cannot care for herself as she had previously with her new injury.

She is admitted to the hospital for optimization of pain control and for evaluation of her care needs as she cannot care for herself as she had previously with her new injury.

That afternoon, her analgesic regimen is continued at her home doses and she expresses to her nurse that she is “in agony” and is observed to be unable to sleep or get comfortable.

Through the night, she receives increasing doses of narcotics throughout the night due to the pain.

At 8 am, she is found to be unarousable and her oxygen saturations fall to 80%. She is given naloxone with improvement in her mental status and oxygenation.  For several hours following the naloxone, she complains of severe uncontrolled pain.

Palliative care is consulted to help optimize her pain control and help delineate her goals for care.  With their help, she is able to sleep adequately and begins to try to move herself around the bed, although she remains totally dependent for care, toileting, and bathing. She is also able to feed herself from a tray and is able to sit up at an incline in bed for short periods of time. She is gradually transitioned back to an increased dose of long-and short-acting oxycodone and is able to maintain effective pain control on those doses.

Ms. Benen remains incontinent of urine and stool and is really depressed and upset about this development. The palliative care chaplain and counselor meet with her daily to help her cope with these changes in her life. She is particularly devastated when her assisted living facility declines to accept her back, as they are unable to meet her new care needs.

The hospital social worker is able to secure a bed in a nursing home 30 minutes from her sister and brother. The social worker informs the palliative care team that this nursing home does not have a palliative care team or consultant, but patients enrolled in hospice care can receive those services in the nursing home.

The palliative care team holds a goals of care meeting with the patient, inviting her sister and brother to take part. The patient’s family expresses support for the patient and willingness to help but inability to meet her care needs at their homes. Ms. Benen acknowledges that she has outlived the life expectancy that she was given by doctors earlier in life and expresses that she wants to be as comfortable as possible for as long as possible.  She does not want any heroic life-saving measures should her health decline.

Hospice services are discussed as well as the usual admission criteria for hospice care. Ms. Benen and her family decide to allow the palliative care team to refer her to hospice. She is accepted by the local hospice organization as a patient, and ultimately is discharged to the nursing home with hospice involvement. 

 

Follow-up:

Ms. Benen lives in the nursing home for four months and is able to spend more time with her brother and sister’s family.

During influenza season, she develops fever, cough, lethargy, mental status changes, and worsening hypoxia. Her family is notified by her nursing home and hospice team about her change in status, and her symptom management is maximized while she is actively dying over the next several days.

After her death, her family follows her written instructions to donate her body to the Willed Body Program at UofL. 

 

Clinical Librarian

Ansley Stuart's picture
Ansley Stuart
Contact:
Health Science Campus
Kornhauser Library, Rm 204
502-852-8534

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