The following history was written from memory by pt’s daughter, Nancy Davis. It probably is pretty accurate, but not 100% so. The last entry is 11/28/04.
Huretta J. Davis
DOB: 10/29/13
Identifying Information: Pt is a 91 y.o., widowed, Caucasian female, retired kindergarten teacher from Chattanooga, TN, who currently lives with her only child, Nancy Davis, in N. Bethesda, MD.
HPI: Except for having osteoporosis, pt was extremely healthy and active until November 2002 when she developed polymyalgia rheumatica, for which she was successfully treated with prednisone and Enbrel. In September 2003, she began developing compression fractures in her spine. Over the past year, she has had 7 vertebroplasty procedures.
Her current acute problems began on 11/3/04 when staff at Sibley Hospital transferred her from the operating table to the stretcher following her 7th vertebroplasty. Despite her telling staff they were going to hit her hand on something, they apparently persisted, and she sustained 2 cuts to her left hand. The nurse put gauze and tape on the wound, and she was transported back to her room. The nurse on the unit noticed her hand was bleeding and dressed the wound. However, within a few days, the hand had become infected, pt was running a fever, felt ill, and was unable to eat or drink adequately.
On 11/9/04, pt was taken by ambulance to Suburban Hospital, where she was found to be dehydrated, malnourished, and in pain from her infected hand and her chronic back problems. She also had a UTI. She was treated with IV antibiotics, fluids, and dilaudid (?). By the next day, her condition was somewhat improved, and she was discharged on 11/10/04 on oral antibiotics. She developed nausea, diarrhea, and loss of appetite and thirst, apparently from the oral antibiotic (levaquin?), and her condition rapidly deteriorated.
On 11/14/04, pt was again taken by ambulance to Suburban Hospital ER, and admitted with essentially the same symptoms as before. She was treated with IV antibiotics, fluids, and dilaudid. The left hand and UTI infections apparently showed a good response to the IV antibiotics. However, she continued to be unable to eat or drink much. A consultation with an infectious disease MD was ordered, and despite being told that pt developed nausea and diarrhea in response to oral antibiotics, the MD prescribed oral levaquin, and her nausea and diarrhea worsened. In fact, when she was being discharged on 11/18/04, she had significant diarrhea, but was discharged anyway, once again on an oral antibiotic ( ), and this time on an anti-fungal medicine ( ) and a 25 mg fentanyl patch. A hospital bed was ordered and received before pt arrived at home.
Pt returned to her and her daughter’s condominium. Potomac Home Healthcare provided a visiting nurse, and pt had other caregivers who provided round-the-clock care. She continued to be nauseated, unable to eat or drink, and sedated. On 11/23/04, Dr. Levin did a house call. He examined her and found no evidence of infection in her left hand, but rather thought the pain was due to inflammation. He suggested we discontinue the antibiotic, which we did, and he prescribed 15 mg Mobic, which pt began on 11/24/04.
As had been the case in the hospital, pt reported extreme pain when she tried to move or anyone tried to move her. The pain was so severe that it was almost impossible to get her on a bedside commode to have a bowel movement. Once again, she had not exactly diarrhea but rather soft stools with a greenish cast.
On 11/24/04, Dr. Arvanaghi, the pain management MD she had seen in the past, ordered a pain pump with .05mg dilaudid every hour plus a.25mg dose prn, in addition to the 25 mg fentanyl patch The combination of the two narcotics, even in small doses, caused such sedation that it was extremely difficult to wake pt, and she would go back to sleep as whoever woke her talked to her. About 6:00 p.m., pt’s daughter removed the fentanyl patch, and within the next couple of hours, pt became a bit more responsive. However, she was again clearly dehydrated, nauseated, and in severe pain.
On 11/25/04, pt was again taken by ambulance to Suburban Hospital ER and readmitted to the hospital.
Previous Surgeries/Procedures
1977 – left hip replaced – Pt fell while running to catch kindergarten student who was running toward the road.
1995 – Cataract surgery in both eyes
9/29/03 -- Nerve Block, L3-L4, Suburban Hospital
11/10/03 – Vertebroplasty, L2 and L3 – Suburban Hospital
?? Vertebroplasty, ?? – Sibley Hospital
2/16/04 -- Lumbar epidural injection, L3-L4 – Sibley Hospital
3/3/04 – Lumbar epidural injection, L3-L4 – Sibley Hospital
6/09/04 – Lumbar epidural injection, L3-L4 – Sibley Hospital
6/17/04 – Lumbar epidural injection, L1-L2 – Sibley Hospital
6/24/04 – Vertebroplasty, T6 and T7(?) – Sibley Hospital
7/19/04 – Vertebroplasty, T9 -- Sibley Hospital
8/12/04 – Lumbar epidural injection, L3-L4 – Sibley Hospital
9/29/04 – Nerve block – Dr. Arvanaghi’s office
10/25/04 – Vertebroplasty, L1 (?) – Sibley Hospital
11/3/04 – Vertebroplasty, T10 (?) – Sibley Hospital
Pain History
One time in 2002 and one time in 2003, pt “turned some way” and got so severe a pain in her back that she fainted. We called 911 the first time, but by the time they arrived, she had regained consciousness and did not go to the hospital.
Throughout the summer of 2003, she was “slowing down,” often preferring to sit in the car while others shopped – a marked departure from her usual behavior. She did not, however, complain of back pain.
On 9/18/03, pt developed her first compression fractures. She was treated with a nerve block and later with vertebroplasty, but she did not take any medicine for pain. Over the next several months, she developed more compression fractures, To manage the pain before she could get another vertebroplasty, pt was tried on several medicines – percocet, Vicadin, Tylenol, and Tylenol with codeine. With each, she developed nausea, hypersomnia, loss of appetite, and inability to eat or drink enough to avoid malnutrition and dehydration. Also, she became rather oppositional, and what felt to others like “wont” was to her “can’t” – e.g., “I can’t eat that. I’ll throw up if I do.”
On 9/17/04 (I believe. We had to cancel some appointments because pt was too nauseated to go.), pt saw Dr. Arvanaghi (301-530-7303) for a pain consultation. He prescribed Ultracet, but once again, pt developed nausea, hypersomnia, loss of appetite, and inability to eat or drink adequately. Dr. Arvanaghi then prescribed fentanyl “lollipops,” but pt develop the same side effects, even on a very small dose (i.e., she would suck on the lollipop for only 2 minutes). On 10/6/04, Dr. Arvanaghi did a nerve block, which controlled the pain for a few weeks until pt developed another compression fracture.
On Monday, 10/25/04, pt had her sixth vertebroplasty, but by the end of the week, it was clear that she had probably fractured another vertebra. While all her other vertebroplasties had been done as outpatient procedures, her pain was so severe that it was extremely difficult to manage her at home.
Pt was hospitalized at Sibley Hospital on 11/2/04 and had her 7th vertebroplasty on 11/3/04. As staff moved her from the operating table to the stretcher to take her back to her room, her hand was cut, and the subsequent infection precipitated the 3 recent ER visits and admissions to Suburban Hospital (see above). Between the 11/03 vertebroplasty and the 11/9 admission to Suburban (I think), Dr. Kellogg prescribed liquid morphine, but once again, pt developed the same symptoms as she did with the other narcotics.
During one or both of her first 2 Suburban admissions, pt was treated with IV dilaudid, which relieved the acute pain in her left hand and, to a limited extent, in her back. [WAS SHE DISCHARGED ON ANY PAIN MEDS THE FIRST HOSPITALIZATION?] However, when she had to be moved (e.g., when she needed to get onto the bedside commode), she experienced very severe pain in her back. On 11/18/04, pt was discharged from Suburban Hospital on an oral antibiotic, oral fungicide, and a 25 mg fentanyl patch. Once again, pt developed nausea, hypersomnia, loss of appetite, and inability to eat or drink adequately, and her condition deteriorated rapidly. She continued to experience severe pain any time she was moved. She could not move herself.
Late on 11/24/04, Dr. Arvanaghi ordered a dilaudid pump, which was set for .05mg/hr, plus an optional dose every 30 minutes of .25mg (I think). He told us to keep on the fentanyl patch. By 11/25/04, pt had again developed all the usual symptoms, but this time it was almost impossible to wake her up. We removed the fentanyl patch, and within a couple of hours, she was easier to arouse. However, her blood pressure was very low, and she was obviously dehydrated and malnourished, and so we again brought her by ambulance back to the Suburban ER, and she was readmitted about 1:00 a.m. on 11/25/04.
On 11/26/04, staff removed the dilaudid pump, and pt was without pain medicine until about 8:00 or 9:00 p.m. At that time, staff helped pt to the bedside commode so she could have a bowel movement, and once again, she experienced extreme back pain. Pt was then treated with methadone, and by 11/27/04, pt once again had developed nausea, hypersomnia, loss of appetite, and inability to eat or drink. Pt was also very confused, thinking various relatives were at the hospital and not knowing which room she was in. If she had not been on IV fluids, she would probably have become dehydrated again.
By 11/27/04, pt was more alert, no longer nauseated, and was able to eat a little breakfast, afternoon snack (3 peanut butter crackers and about ½ cup of coca-cola), and dinner (a few bites of turkey and dressing, mashed potatoes, and carrots).
On 11/28/04, she ate a little breakfast and was feeling ok until about 11:45 a.m. when she was given potassium in orange juice, which she promptly threw up.
