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Dr. Chip
Dr. Chip, Doctor (MD)
Category: Health
Satisfied Customers: 22536
Experience:  Over 20 yrs of Family Practice
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My Mother is 100 years old in terrific shape for her age, mobile,

Customer Question

My Mother is 100 years old in terrific shape for her age, mobile, some dimentia, great appetite, enjoys riding in the car, music, etc. One night about 7 pm she was with her caretaker and I came home from work to find her paranoid, delusional, hallucinating, kicking and picking at the air. I called paramedics, went to emergency. The hospital looked for stroke or seizure but found neither. However she stayed 7 days on anti seizure medication sedated in bed imobile. She bounced back to herself, came home, 2 days later she had 8 hours of diarehea (the worst I have ever seen) two days after that I took her to emergency with breathing problem and listless. They diagnosed pneumonia. She responded to antibiotics on the 6th day (three IV levofloxacin, amoxicillin and one that started with a "Z"). This is the 12th day. She has been off O2 for 5 days, no IV fluids or antibiotics for 3 days. She is sleeping peacefully and breathing is slow and deep. Oxygen level 97 all vitals normal! Now here is my question...the intermal medicine doctor is telling me she is going to die due to aspiration and the lung doctor is questioning that prognosis. The lung doctors orders are being cancelled by the internal med doctor. How do I know who is being straightforward with the cause of this pneumonia...how do you tell is Mom is inhaling her own saliva or if she caught the bacteria in the hospital on her last stay?? I hope you can answer this. Hospital is kicking her out today.
Submitted: 1 year ago.
Category: Health
Expert:  Dr. Chip replied 1 year ago.
Hi--what exactly did the internist say was going to be the cause of death? What orders were cancelled?
Customer: replied 1 year ago.

Internal medicine doctor said she would continually swallow her saliva and kill herself with subsequent pneumonias. The speech therapist in the room said she swallowed well with good movement on swallowing an ice cube. Mom spit the Bariam at the other therapist duing the Barium swallow test yet that girl wrote in her chart that she failed the test and I wasn't allowed to give her food. Mom begged for food for days. the Lung specialist is thinking we don't really know how she got pneumonia, she won't take the swallow test, let's try her on food and move her around. He has ordered regular diet and physical therapy. Some one overruled him and cancelled her therapy and cancelled all fluids. She is too weak at this point to eat enough to survive and they will not give her fluids!

Expert:  Dr. Chip replied 1 year ago.
So before all this happened was there any problem with her swallowing and had she ever had pneumonia before?
Customer: replied 1 year ago.

NO...she had some allergies in February which her regualar doctor said caused bronchitis. Oh yes...I forgot to tell you. She came home from the first hospital stay (for delerium) with a bladder infection. The bladder infection was discovered when she had the pneumonia.


 


She hollars and yells and feeds herself and goes non stop all day moving around the house until she got the pneumonia.

Expert:  Dr. Chip replied 1 year ago.
OK--but you say she's being discharged and are you saying she's really too weak to eat or drink anything?
Customer: replied 1 year ago.

Yes. She is on Medicaid. they never wanted to treat her in the first place. The Inter Med dr. just called and said she did not know if the pneumonia was cleared or not but they gave her all the antibiotics she was entitled to. This doctor still says she is aspirating her saliva. No test has proven this. Her cough could just be from the pneumonia. they want her out of the hospital NOW before she is strong enough to eat. They stopped fluids and antibiotics. I just asked for IV fluids again. Mom is talking to people in the room today. They are pushing me into Hospice and refusing therapy or fluids. I think she has lost over 10 pounds.

Expert:  Dr. Chip replied 1 year ago.
OK--sorry about all this but are you asking just whether I think she has a swallowing problem?
Customer: replied 1 year ago.

How can you know if the pneumonia is caused by inhaling your own saliva or by inhaling bacteria in the air from her last hospital visit?


How can you tell if she has a swallowing problem?

Expert:  Dr. Chip replied 1 year ago.
Well, aspiration pneumonia isn't initially a bacterial or viral infection--it's purely inflammation from gastric acid to start with and sometimes there is overgrowth with bacteria from the environment. This doesn't sound like an aspiration pneumonia to me and I don't think she has a swallowing problem but that can be checked with an esophageal manometric test with a probe if she won't allow the barium swallowing test. I certainly would allow her to eat and drink at this point some Ensure puddings for now.
Customer: replied 1 year ago.


Would the strain of bacteria help to diagnose whether it was aspiration pneumonia or acquired pneumonia?


 


Is more than 10 days antibiotic needed? Should they do a final CTscan?

Expert:  Dr. Chip replied 1 year ago.
Well, if the bacteria was staph as in MRSA or say pseudomonas that would speak to it's being hospital acquired for certain. As for the 10 days that may have been appropriate based on the cultures but some infections take two to three weeks of antibiotics. Only another chest x-ray would be needed to check on the status of the pneumonia
Customer: replied 1 year ago.

When I asked the internal med doctor if the pneumonia had cleared she stuttered and said I don't know...she is going to get it anyway again.


I will ask for the x-ray.


My friend just sent me her picture on my phone. she is happy and smiling in bed.


 


You were great. Thank you.

Expert:  Dr. Chip replied 1 year ago.
My pleasure but please let me know how it goes with her and remember to rate my service to you
Dr. Chip, Doctor (MD)
Category: Health
Satisfied Customers: 22536
Experience: Over 20 yrs of Family Practice
Dr. Chip and 2 other Health Specialists are ready to help you
Customer: replied 1 year ago.

I went to the hospital last night and the pulmonary doctor said he would not take a final x-ray of her chest for the pneumonia but we could come back in 4 weeks for that. He said they are discharging her based on the fact she is breathing without oxygen. He said there was no use in taking the x ray because she would get the pneumonia again from aspiration again anyway and die. The Barium test remember was never completed cuz mom spit it out and yet the speech therapist said she in her chart that she aspirated! They refused her any physical therapy. I had to set up Hospice to help me handle her at home. Today she ate a muffin, oatmeal and some insure without coughing. Yesterday the speech therapist would not let the nurse thicken her fluids and insisted that she drink regular water.What is going on?

Expert:  Dr. Chip replied 1 year ago.
I thought the pulmonologist was the one that didn't think she had an aspiration problem?
Customer: replied 1 year ago.

That doctor hasn't seen her since Monday when he disagreed with everyone else in the room during the pow wow. His associate comes, stands in the room, never listens to her chest, makes a face and says she is never going to get well. I have left 5 messages with Dr. Kollipara's service and he does not return my call. He was voted most compassionate Dr. at this hospital. I cannot reach him now.

Expert:  Dr. Chip replied 1 year ago.
OK--well if she's doing that well, no need for the x-ray. I don't get it though--one episode of possible aspiration and they think it's going to happen again? Why do they think she has a swallowing problem?
Customer: replied 1 year ago.

I have no idea. No test, never choked, no underlying illness, she never even had to see a doctor for a cold in the last 4 years, doesn't drool, she could break your arm she is so strong when she has not been shot with Ativan.


I have no clue why the Internal Medicine doctor said that but now everyone is jumping on the bank wagon. The physical therapy orders were cancelled twice by the Internal medicine doctor. I got a copy of the notes in her chart from someone undercover last night. the Hospice lady said what Mom caught from her first hospital stay was the Rota virus which is going around that hospital. The first speech therapist let her swallow an ice cube and felt her throat and said she had good movement. Now she does not come back either.

Expert:  Dr. Chip replied 1 year ago.
OK--how can I now help you with this?
Customer: replied 1 year ago.

For now my focus is on helping Mom regain her physical strength. After being confined to bed for almost 3 weeks should I try to sit her in a chair at home, her wheelchair or in bed again? I don't want to stress her out too much and don't know how to proceed assuming she can eat OK. How long should she be able to be up?

Expert:  Dr. Chip replied 1 year ago.
OK--how is she mentally and how does she do sitting up in bed?
Customer: replied 1 year ago.

The nurse tech sat her up in bed with legs dangling for 15 minutes today. That was her first try for 3 weeks in bed. Mentally she is raring to go but talks as if her Father and brothers are waiting for her somewhere. She has her fantasy dymentia moments then she will follow commands like hold here, stand up, turn your feet etc.

Expert:  Dr. Chip replied 1 year ago.
OK--first off she definitely needs food--supplemented perhaps with Ensure. I'd get her into a chair and three times a day but she also needs to walk a little--with careful assistance and monitoring, of course. It sounds to me as though there never was a swallowing problem and she's over the worst of the pneumonia but it may take several weeks for he to get all her strength back
Customer: replied 1 year ago.

It has been a roller coaster since getting her home. She returned on Friday. Saturday she ate a jelly sandwich and two glasses of juice. Slept well and did not want to get up on Sunday. She was lethargic and combative in the morning. After a nap she woke with a smile and drank a large glass of juice and said it was good. She wiggled her feet and waved at me in the kitchen and was feeling good. She went to sleep and did not want to get up on Monday. I forced her to sit in a chair but she spit out the juice etc. at me and just slept. I took her to our physician at 1 who reviewed the hospital notes, tested her urine and blood. No infection, O2 level 95, lungs fairly clear but listless from dehydration. Hospice would not send fluids. My doctor talked them into one bag and they only let her have 750 CC cause they did not want to move the IV which had intabated. she is eating some pudding and a little juice. Now, my doctor said her kidney tested poorly. My choices were emergency room for fluids or hospice fluids. Is 750 enough to see if we can improve her kidney function? The hospital said her kidneys were working as well as could be expected at her age. If I give her more fluids I will have to carry her to another emergency room. What should I do? Oh...her fluid outtake was same as intake.

Expert:  Dr. Chip replied 1 year ago.
Sorry--by outtake you mean her urine output?
Customer: replied 1 year ago.


Yes she has a catheter. It filled up the same amount as what had come out of the bag of fluids over the night. they are dripping very slowly...40 in a 10 hour period. Saline only. Her creatine in hospital measured 1.2/1.4/1.6and it varied. Yet in 2011 it was also 1.4 on an occasion in the hospital.

Expert:  Dr. Chip replied 1 year ago.
And do you think you can get her to orally take in more fluids?
Customer: replied 1 year ago.

she is taking in some fluids voluntarily. It depends. Night before last she downed 8 oz of cranberry juice. But with her sleeping so much we cannot be consistent.

Expert:  Dr. Chip replied 1 year ago.
Well for now the 750cc along with oral fluids if she can take a little more should be OK and at least the creatinine numbers don't indicate kidney failure right now. Try to see how she does over the next two days with that before you consider taking her to the ER
Customer: replied 1 year ago.

Good. Are there services who could deliver fluids to the house?? Can I get the doctor to order this if needed in a few days?

Expert:  Dr. Chip replied 1 year ago.
Yes--medical supply services can do that if the doctor will order them
Customer: replied 1 year ago.

Thank you

Expert:  Dr. Chip replied 1 year ago.
Again, my pleasure but remember to rate my service to you
Dr. Chip, Doctor (MD)
Category: Health
Satisfied Customers: 22536
Experience: Over 20 yrs of Family Practice
Dr. Chip and 2 other Health Specialists are ready to help you
Customer: replied 1 year ago.

Yesterday was a better day. she said she was hungry and ate a few bites of cooked brocoli and some pasta. she drank 550 ml pedialyte and her catheter this morning had over 300ml in it dark yellow but not brown. she was alert and awake from 4:30 am until 9pm. Just napped some during the day in the recliner chair. no coughing . today she did not want to wake up but she was coherant at 1 am asking me to lay my head on a pillow.


By the way I got a copy of her hospital report which says in writing "hospital acquired pneumonia" NOT "aspiration pneumonia" like I was told. her renal function was listed as stage 3 to 4 creatin level "a H/OCKD stage 4 on the 11th creatine=1.2. sonogram shows bilateral cystic change C/W CKD. Etiology of CKD hypertensive Nephropathy. What does that mean? No one ever told me this when we were in the hospital. the kidney doctor said she was funcitioning well for 100 years. How poorly are the kidneys working?

Expert:  Dr. Chip replied 1 year ago.
CKD=chronic kidney disease and the sonogram just established that she has cysts in her kidneys. Hypertensive nephropathy means kidney damage and falure due to long standing high blood pressure. If she's making urine then her kidneys are still functioning even though stage 4 is know as end stage renal disease. If she were say thirty or more years younger a kidney transplant would be considered. She may or may not need dialysis in the future but she's had kidney disease for a long time. H/O CKD=history of chronic kidney disease
Customer: replied 1 year ago.

OK so treatment at this point would be what? Would she do better with IV fluids? with or without glucose?

Expert:  Dr. Chip replied 1 year ago.
For the kidneys, a low protein diet and maybe an ACE inhibitor blood pressure medication. Good hydration and for now it sounds as though she doesn't need more IV fluids, but, if she did, 1/2 normal saline with 5% glucose
Customer: replied 1 year ago.


are you saying...1/2 bag of saline or more dilute saline? dont understand.


 


Good hydration? she is only drinking 500 ml per day. is that good?

Expert:  Dr. Chip replied 1 year ago.
No 1/2 normal means the concentration of sodium chloride in sterile water. If she can't take in at least a liter of fluids per day she'll need at least a liter of IV fluids per day in addition to what she can take in orally
Customer: replied 1 year ago.

thank you. I will get back to you later tonight. thanks.

Expert:  Dr. Chip replied 1 year ago.
My pleasure again
Customer: replied 1 year ago.

Just an update. Mom is eating small amount and drinking about 600ml per day with the same amount of urine going into the catheter. She stood up today with 50% support and asking to use the bathroom. Her digestive system is functioning. She is starting to feed herself. She is still tired, sleeping from 9 pm to 8 am and napping during the day some. What foods do your suggest to start her on beside the Insure? She said she is tired of that sweet taste.

Expert:  Dr. Chip replied 1 year ago.
Sounds good so far and sounds like she doesn't have a swallowing problem. What is she eating now besides the Ensure?
Customer: replied 1 year ago.


Mashed potatoes, overcooked veggies, applesause, yogurt, pudding.


I get scared when she clears her throat. should I take her for a swallowing test?

Expert:  Dr. Chip replied 1 year ago.
Tell me more about the clearing her throat thing first
Customer: replied 1 year ago.

Not all the time but sometimes a few seconds after she drinks she has a small cough like clearing your throat. I am still thickening her liquids to a nector consistency. She did not do that before she went into the hospital that I remember. When she had the ice cube test in the hospital the therapist said she had good throat movement but her superior insisted that she cleared her throat after she had barium in her mouth. When she is asleep she does not cough. When she is sitting up she does not cough. Only sometimes she does that after she drinks.

Expert:  Dr. Chip replied 1 year ago.
It really doesn't sound like a problem with swallowing still so I don't think she needs the test, especially since she seems to be doing well otherwise. I think you can begin giving her something other than a nearly pureed diet now and I'd suggest chicken and fish along with bread and fruits
Customer: replied 1 year ago.

She did chew the cookie just fine. I will give her some protein. She asked for water last night so she is not afraid to drink. Should I keep thickening her liquids?

Expert:  Dr. Chip replied 1 year ago.
I don't think you need to thicken them since I don't think she has a swallowing problem
Customer: replied 1 year ago.

OK thanks.

Expert:  Dr. Chip replied 1 year ago.
Any time

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