Case 994: Lily
Patient: Lily, an 85 year old woman

Principal complaints: Lily's son has brought Lily to see you today because he is concerned about her loss of strength. Lily is also concerned about constipation.

    One year ago, Lily experienced an episode of severe pain in her hip which was diagnosed as osteoporosis of the spine and pelvis. She was treated with calcium, calcitonin and Fosimax. Since she was able to walk only with great difficulty, she moved in with her son who cared for her. She responded well to this treatment and after several months she was able to walk and preform most of the chores of daily living without assistance. The calcium and calcitonin were discontinued. She returned to her home in a rural area of Maine; however, her children insisted that Lily hire a personal assistant to prepare food, assist with bathing, shopping and other chores.
    The assistant arrives daily at 9:00 AM and prepares and serves breakfast and lunch. She leaves at 2:00 PM after preparing a dinner which she leaves on a plate in the refrigerator for Lily to heat in the microwave later. She also dishes a bowl of ice cream and leaves it in the freezer. Lily eats this before bed.
    About 1 month ago, Lily called her urologist and said that she was having difficulty sleeping at night because she had to go to the bathroom so often. A urinary tract infection was ruled out and the urologist prescribed amitriptyline 50 mg at 5:00 PM.
    A visiting nurse comes to Lily's home once a week. Over the last several weeks the nurse has observed that Lily seems to be losing strength. She now requires assistance to get up from a chair and has difficulty opening drawers. She also used to take a short walk every day which she no longer does. The personal assistant corroborates these observations and adds that Lily requires much more assistance with dressing and sometimes seems disoriented when she arrives in the morning. The assistant also notes that in the last month, Lily has frequently not eaten her dinner or the ice cream. The assistant often finds the uneaten meal in the refrigerator or the microwave. When she has asked Lily about it, Lily said that she must not have been hungry so she forgot to eat. Lily has also been refusing fluids so she won't have to get up so often to go to the bathroom.
    The nurse called Lily's son and informed him of her concerns and he called you for an appointment.

Observations from the physical exam:
Lily is pleasant and cooperative. She is thin and pale and appears tired. Her gate is somewhat unsteady and she has difficulty getting up from the chair.

Height and weight:
Two years ago One year ago Today
Height 5'2" 5' 4'10"
Weight 125 lbs. 115 lbs. 100 lbs.

Diet Intake:
Breakfast V-8 juice, 1 cup
Wheat toast, 1 slice
Muenster cheese 1 oz.
Lunch Tomato soup, 1 cup
Saltines, 4
Dinner * Chicken, 6 oz.
Rice Pilaf, 0.5 cup
String beans, 0.5 cup
Pears, canned, 0.5 cup
Snack * Ice cream, 1 cup
* the assistant estimates that Lily has only eaten dinner and snack about 10 times in the last month.
Laboratory tests: Within normal range except for :
Lily normal
Albumin (g/dl) 2.5 3.2-3.8
Na (mEq/L) 146 136-142
K (mEq/L) 5.1 3.8-5.0
BUN (mg/dL) 26 8-23

Values for hematocrit and hemoglobin were within normal range.

Fosimax, Vitamin and mineral supplement (Geritol), amitriptyline