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Case Conference November 20 th, 2012 Jiten Patel & Alisha Lacour.

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Presentation on theme: "Case Conference November 20 th, 2012 Jiten Patel & Alisha Lacour."— Presentation transcript:

1 Case Conference November 20 th, 2012 Jiten Patel & Alisha Lacour

2   Headache X 1 week Chief Complaint

3   49 year old woman with history of COPD and nephrolithiasis (first diagnosed 2011)  4 Weeks ago:  She presented to an outside hospital with urinary symptoms, nausea, vomiting and flank pain. HPI

4   4 Weeks ago:  Urine cultures showed mixed flora  Sent home on ciprofloxacin  Follow-up with urology.  She presented to the urology clinic 2-3 days later  Clinically looked poor so she was admitted from the clinic for:  IV antibiotics  Placement of stents for hydronephrosis.  She was sent home with ciprofloxacin and clindamycin  Urine cultures drawn prior to discharge were negative.. HPI

5   2 Weeks ago:  Followed up with urology  Had successful laser ablation of the kidney stone  5 days ago:  She presented to the an outside hospital complaining of a headache  Constant and aching  Fluctuated in intensity from 8/10 to 10/10  No radiation  Diffusely throughout the head  No alleviating factors  Worsened by light and sounds HPI Continued

6   5 days ago (cont.):  CT showed a possible subarachnoid hemorrhage  She was transferred to UH for neurosurgical evaluation.  She was admitted by neurosurgery and observed in the ICU.  A repeat head CT showed a stable subarachnoid hemorrhage  She was discharged home with follow-up. HPI Continued

7   3 days ago  After being home for a few days she presented to UH with persistent headache.  Also complained of:  Mild dysuria  No increase in frequency or incontinence  No flank pain  Low grade fevers HPI Continued

8   Kidney Stones  ESWL 2011  COPD Past Medical History

9   Cystolithotomy 2005 Past Surgical History

10   Ciprofloxicin 500mg PO BID  Oxycodone-Acetaminophin 5-325mg PO Q4-6 hours  Tamsulosin 0.4mg PO QDay Medications

11   Penicillin – swelling of extremities Allergies

12   Father passed away from cardiac disease – 70’s  Mother passed away from lung cancer – 60’s  Siblings healthy  Several family members with kidney stones Family History

13   Smokes 1-2 packs per day for 35 years  Quit 3 weeks ago  Denies any current alcohol use  Denies any illicts  Lives with her fiancé Social History

14   Up to date on influenza immunization  Up to date on pneumococcal immunization  Up to date on Tetanus immunization  Up to date on PAP  Up to date on Mammogram  No colonoscopy Health Maintenance

15   Gen: No weight changes  HEENT: no visual changes, sore throat, rhinorrhea  CV: Per HPI  RESP: Per HPI  GI: no N/V/D/C/melena/BRBPR  Neuro: No dizziness, numbness, seizure  Skin: no new rashes  GU: Per HPI ROS

16   Vitals  Triage  BP 110/60 P 68 RR 18 T 99.2 O2 100% on RA  5’6” 77kg BMI 27  Exam  BP 125/79 P 61 RR 16 T 98.8 O2 98% on RA Physical Exam

17   GENERAL: Awake, alert, and oriented. No acute distress.  HEENT: The patient does have a hyperpigmentation over her left eyebrow. Normocephalic, atraumatic. Mucous membranes are slightly dry. No papilledema.  CARDIOVASCULAR: Regular rate and rhythm. No murmurs  RESPIRATORY: Mild expiratory wheezing bilaterally.  ABDOMEN: Bowel sounds present. Soft. Nontender. Nondistended.  EXTREMITIES: No clubbing, cyanosis, or edema. Physical Exam

18   NEUROLOGIC:  Mental: Awake, alert, and oriented x4.  Sensation intact to light touch.  Reflexes are 2+ in biceps, triceps, patellar, ankle  Strength is 5/5 bilaterally in the upper and lower extremities.  Cerebellar function intact to finger to nose and heel to shin  CN II-XII: EOMI intact, PERRLA, sensation intact to light touch, raises eyebrows, closes eyes tight, symmetric smile, tongue midline, good palate elevation, phonation/cough intact, shoulder shrug appropriate Physical Exam

19  Labs OSH (Day prior) 134 98 13 3.8 29 0.93 (24-32) 131 Ca 8.2 (8.4-10.3) Mg 1.6 P 2.1 TP Alb TB AST ALT ALP 7.2 2.7 1.6 20 20 61 (3.5-5.0)(<1.3) Received dose of Gentamicin UA: Sg pH Prot Glu Ket Bili Blood Nitrite Urobiligin LE 1.010 7.0 25 Neg 25 Pos 4.0 500 RBC6-10 WBC>100 Sq20-100 BactMany Casts3-5 Hyaline (4.5-11.0) 18.0 224 13.3 40.0 N 92 L 4 M 3 93 13.3

20  Labs Admit 134 102 13 4.0 26 0.9 150 Ca 8.5 Mg 1.6 P 2.1 Blood Cultures drawn UA: Sg pH Prot Glu Ket Bili Blood Nitrite Urobil LE 1.011 7.0 25 Neg 25 Neg 8.0 500 RBC0-2 WBC3-5 Sq1-2 Bactnegative Casts0 (4.5-11.0) 13.9 224 12.6 36.2 N 96 L 3 M 1 93 13.3

21  CT Head 2/18

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24  CTA Brain (2/19)

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26  CT Brain (2/24)

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28   LP  CSF Clear  Glucose 12  Total Protein 100.4  WBC 198  SEGS 67%  LYMPHOCYTES 33%  RBC 0  Gram Stain:  Many WBC’s  Few Gram negative rods Labs

29  Gram Stain

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32   She was admitted:  Placed in respiratory isolation  Treated with:  Dexamethasone  Vancomycin  Imipenem due to her penicillin allergy.  Her headache improved. Hospital Course

33   Day 2:  Urine Cx from OSH:  E. Coli >100,000  Resistant to Ciprofloxacin  Susceptible to ticarcillin/clavulinate, ampicillin, gentamicin, nitrofurantoin, piperacillin/tazobactam, ampicillin/sublactam, tetracycline, cefazolin  Intermediate to cephalothin  Blood Cxs and CSF Cxs with  Gram negative rods Hospital Coarse

34  MRI Brain

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45  MRA Brain

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47   Day 3 of hospital course  She had a seizure sending her to the ICU  Cause due to the carbapenem or meningitis  Neurology was consulted  EEG done  Mild to moderate abnormality  Diffuse slowing  Excessive beta activity  Imipenem stopped and treated with gentamicin Hospital Course

48   Repeat LP  Clear  Glu 37  Pro 64  WBC 130  N 9% L 89% M 2%  RBC 0  Gram Stain:  No Organisms Hospital Coarse

49   Hospital Day 4  Initial Blood and CSF cultures :  E. Coli  CSF sensitive to aztreonam, ampicillin, piperacillin/tazobactam, imipenem  Blood sensitive with above and gentamicin, bactrim, cefazolin  Blood resistant to ciprofloxicin, moxifloxicin  Antibiotics changed to aztreonam  Somnolent from seizure  Hospital Day 6  Clinically improved  Reported feeling the best she had in weeks  Stepped down to the floor Hospital Course

50   Hospital Day 7  Became more lethargic  On call intern notified  Evaluated patient, noted papilledema  STAT CT head Ordered Hospital Course

51  CT Brain

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58   Transferred back to ICU  Neurosurgery Consulted  Subdural Hematoma with midline shift  Taken to the OR for emergent hemicraniotomy  Mental status did not improve  Family elected for palliative care  Passed away Hospital Course

59   Thank You


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