Corridor Consult - a visit to a group home

Paul at home - click above to view video.

This case discusses the diagnostic dilemma in a patient with intellectual disability and limited mobility. The clinical scenario offers various options to explain the patient’s deterioration and increased number of seizures. The participant is encouraged to consider all the possible explanations and is assisted in reaching a diagnosis and management decision.

Learning objectives:

• Assessment and management of pneumonia in the community.
• Ensure patient safety by being aware of potential risks associated with swallowing difficulties.

You are a busy GP in a small group practice.

On Monday morning you receive a message that a visit is needed to a group home for young adults with physical and intellectual disability, for whom you have cared over many years. The patient is Paul.

Your practice nurse rang the group home to triage the situation and has reported that Paul has been fitting a bit more over the weekend and appears a bit lethargic today. The staff member in the home has minimal medical training but says Paul does not have a temperature or other symptoms that may indicate a respiratory or urinary tract infection.

Paul is a 31 year old male who has severe cerebral palsy and intellectual disability.^{[1][2][3][4][5]}

He is wheelchair bound due to a spastic quadriplegia. He has a history of epilepsy from birth that is currently modified and controlled on Carbamazepine 400 mg b.d. and sodium valproate 1000mg b.d..

Paul is assisted in feeding as well as transfers and toileting. He is on thickened fluids and had a swallow assessment just 6 weeks ago.

At lunch you visit Paul in his house and note that he appears less responsive. The staff member says he has been twitching a lot more and his appetite is poor.

You had some blood tests done just last week that revealed a Sodium level of 128mmol/L with both Carbamazepine and Na Valproate levels being within normal limits. Paul's Sodium levels have been lowish in the past due to the effect of his antiepileptic medication on the Anti Diuretic Hormone levels.^[6][7]

This is managed by daily water restriction to 800 ml.

A sample CXR showing a left lower lobe pneumonia.

On examination;

• BP = 105/70
• Pulse = 70 regular
• T = 36.5ºC
• Urinary Annalysis - No Abnormalities (dip stick taken from incontinence pad)

Paul’s chest appears to have reduced air entry left base but examination is difficult as Paul has severe kyphosis and scoliosis due to spasticity.

A CXR reveals a left lower lobe pneumonia.

You order a repeat urea and electrolytes test as well as an FBC, blood film and differential call count to evaluate the underlying pathogen.

In the interim you commence antibiotics and use dual therapy of Amoxycillin and Roxithromycin to cover the prospect of a community acquired pneumonia.^[8][9]



Based on your experience and knowledge, please comment below on Paul’s overall management and the management of this episode in particular.