A 74-year-old woman is brought to the emergency department with fever, chills, and shortness of breath. Two days ago, she choked while having tea and doughnuts and almost lost consciousness. Her son performed the Heimlich maneuver. The patient has advanced Alzheimer dementia, and her son is her health care proxy and primary caregiver; her 73-year-old husband also participates in her care. Her other medical problems include hypertension, hyperlipidemia, coronary heart disease, ischemic stroke with mild residual right hemiparesis, history of heme-positive stools, and urine incontinence. She is allergic to penicillin (anaphylaxis). Her temperature is 38.9 C (102 F), blood pressure is 120/80 mm Hg, pulse is 92/min, and respirations are 24/min. Pulse oxymetry shows 89% on room air and 94% on 40% facemask oxygen. Auscultation of the chest shows crackles at the right lung base. The heart sounds are regular. There is no jugular venous distension. The abdomen is soft, nontender, and nondistended. There is no peripheral edema. Laboratory results are as follows: A portable chest x-ray shows a right lower-lobe infiltrate.
With the appropriate treatment, the patient's kidney function recovers. She is afebrile with mild persistent cough and is ambulating without difficulties. She is now ready to be discharged. Which of the following is most important to perform before discharging the patient?

Question

A 74-year-old woman is brought to the emergency department with fever, chills, and shortness of breath.  Two days ago, she choked while having tea and doughnuts and almost lost consciousness.  Her son performed the Heimlich maneuver.  The patient has advanced Alzheimer dementia, and her son is her health care proxy and primary caregiver; her 73-year-old husband also participates in her care.  Her other medical problems include hypertension, hyperlipidemia, coronary heart disease, ischemic stroke with mild residual right hemiparesis, history of heme-positive stools, and urine incontinence.  She is allergic to penicillin (anaphylaxis).  Her temperature is 38.9 C (102 F), blood pressure is 120/80 mm Hg, pulse is 92/min, and respirations are 24/min.  Pulse oxymetry shows 89% on room air and 94% on 40% facemask oxygen.  Auscultation of the chest shows crackles at the right lung base.  The heart sounds are regular.  There is no jugular venous distension.  The abdomen is soft, nontender, and nondistended.  There is no peripheral edema.  Laboratory results are as follows:  A portable chest x-ray shows a right lower-lobe infiltrate.
With the appropriate treatment, the patient's kidney function recovers.  She is afebrile with mild persistent cough and is ambulating without difficulties.  She is now ready to be discharged.  Which of the following is most important to perform before discharging the patient?

Quizplus · Accepted Answer

Explanation: This patient's problem initially began with aspiration of food. Given her advanced dementia, a swallowing dysfunction is very probable. Therefore, before discharging this patient, it is advisable to ensure that a speech therapist has performed a speech and swallow evaluation. Diet modification is typically required and is preferred over continuation of the same type of food under supervision. (Choice A) The patient appears to have a reasonable support system at home with her son and husband. (Choice B) The patient must be evaluated for swallowing dysfunction before consideration of percutaneous endoscopic gastrostomy (PEG) tube placement. Furthermore, it is unclear whether PEG tubes prevent future aspiration episodes or improve long-term survival for patients with swallowing difficulties. (Choice C) The patient is ambulating without difficulty and likely does not need intensive inpatient rehabilitation. Physical therapy is important for the assessment of gait and balance and prevention of falls; however, it will not help prevent aspiration episodes. (Choice E) Home safety assessment is designed to help reduce accidents at home in elderly patients, particularly accidents due to falls. This patient's illness was due to aspiration. Educational objective: Speech and swallowing evaluation, followed by diet modification, is performed in high-risk patients to prevent future episodes of aspiration. It is unclear whether percutaneous endoscopic gastrostomy tube placement prevents aspiration episodes or improves long-term survival of patients with swallowing difficulties. References: Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances. (http://www.ncbi.nlm.nih.gov/pubmed/21069702)

A 74-Year-Old Woman Is Brought to the Emergency Department with Fever