2. INTRODUCTION:
54 YRS OLD LADY ON THRICE WEEKLY DIALYSIS PRESENTED IN ER
WITH DROWSINESS ON 25TH SEPTEMBER 2019
HER LAST DIALYSIS WAS ON THE DAY BEFORE AND ACCORDING TO
THE FAMILY SHE BECAME DROWSY AFTER THAT
WAS HAVING LOW GRADE FEVER ACCOMPANIED BY VOMITING ,
NAUSEA AND GENERALIZED WEAKNESS FOR 5 DAYS
COMORBIDS: DM HTN ESRD ON MAINTAINANCE HDX VIA AVF LT ARM
3. EXAMINATION:
BP 164/77 MMHG PULSE 97/ MIN SPO2 98% RR 20/MIN
DROWSY BUT AROUSABLE CONFUSED NOT OBEYING COMMANDS
GLOBAL APHASIA
B/L PLANTARS MUTE
NECK RIGIDITY NEG
RT UPPER LIMB FLACID
LOCALIZING PAIN WITH LT HAND
CHEST HVB
5. HOME MEDICATIONS:
INJ LANTUS 16 UNITS OD
INJ NOVORAPID 6 UNITS WITH MEALS
TAB VILDOS 50MG BD
TAB HYDRALAZINE 25MG 2 TDS
TAB STAT A 10MG HS
CAP RULING 40MG OD
TAB CARDURA 2MG BD
TAB IMDURE 60MG BD
TAB ONE ALPHA 2MG OD
CAP ZEEGAB 75MG HS
TAB SALVER 400MG TDS
INJ MERCERSA 100MCG ONCE MONTHLY
7. IMPRESSION IN ER:
CVA (ISCHEMIC VS HEMORRHAGIC)VS CNS HEMATOMA
CNS INFECTION
ELECTROLYTE IMBALANCE RELATED TO Ca Na
SEPSIS SECONDARY TO :
oASPIRATION PNEUMONIA
oLRTI/UTI
oCEREBRAL MALARIA
9. CT SCAN REPORT: 25/9/19
Old lacunar infarction in left pre-insular cortex, however no recent
gross area of infarction or intracranial
hemorrhage identified.
No mass effect or midline shift noted.
Normal ventricular system.
No abnormality seen in the brain stem and posterior fossa.
No extra-dural or subdural hematoma or collection.
Normal both orbits. Visualized paranasal sinuses are clear.
10. NEUROLOGY TEAM HAD IMPRESSION OF ACUTE STROKE AND
ENCPHALOPATHY SECONDARY TO UREMIA
ADVICED MRI MRV MRA AND METABOLIC WORKUP
DUAL ANTIPLATELLATES STARTED WITH ALPHA CHLINE
11. HB 10.1 PLT 205 TLC 13.8
UREA 95 CR 6.8 NA 139 K 4.8 HCO3 25 CL 99
CA 9.05 PO4 4.5 MG 2.3
12. NEXT DAY SHE WAS DIALIZED AS ROUTINE
HAD 100 F FEVER AND REMAIN DROWSY GCS 10/15
LP WAS DONE ON 26TH SEPT 2019
HAD TACHECARDIA WITH T WAVES INVERSION
TROPS LEAKED 0.5 TO 1.2 THEN 0.87
13.
14. ANTIBIOTICS WERE CHANGED TO CEFTRIAXONE VANCOMYCIN AND
AMICILLIN IN MENINGITIC DOSES.
MRI BRAIN WITH CONTRAST WAS PLANNED BUT MACHINE WAS OUT
OF ORDER
OVER NEXT 2 TO 3 DAYS BECAME LESS IRRITABLE AND
COMMUNICATING FOLLOWING 2 STEP COMMAND
FEVER SETTLED
WAS SHIFTED OUT IN WARD
ROUTINE CS AFB SMEAR ADA CAME NEG
HSV PCR WAS AWAITED
15. ON AND OFF SPELLS OF DROWSINESS IMPROVING WITH DIALYSIS
NG WAS REMOVED AND ORALLY ALLOWED.
FAMILY WAS ADVICED DISCHARGE BUT OPTED TO REMAIN IN
HOSPITAL FOR THE REMINDER OF ANTIBIOTIC TREATMENT ON 2ND
OCTOBER 2019
ABOUT 1 WEEK AFTER ADMISSION AGAIN BECAME FEBRILE 101 WITH
INCREASED DROSINESS IRRELEVENT TALK AND JERKY MOVEMENTS
CXR CLEAR NO SIGNS OF PHLEBITIS
RESHIFTED TO MICU
16. IMPRESSION OF SEIZURES/NON RESPONDING MENINGIOENCAPH/POST
ECAP PSYCOSIS WAS MADE
MRI BRAIN WITH CONTRAST PLANNED
EEG : EPILPTIC DISCHARGES AND ENCEPHALOPATHY
REPEAT LP WAS ADVICED BUT REFUSED BY FAMILY
TAKEN ON INJ EPIVAL AFTER CONSULTING NEUROLOGY
17. MRI WITH CONTRAST: 4/10/19
Mild microvascular ischemic changes are present in white matter of both
fronto-parietal lobe. Small focal ischemic demyelinations is present in pons.
No recent infarction, hemorrhage or space occupying lesion is present in
brain.
No unusual post contrast enhancement or enhancing lesion is present in
brain and meninges.
Mild age appropriate involutional changes noted in brain with deepened
cortical sulci and prominent ventricular system.
No extradural or subdural hematoma or collection is present.
No midline shift is present.
Bilateral basal ganglia and thalami are normal.
On concomitant MRV images, there is no evidence of cerebral dural venous
sinus thrombosis
18. PATIENT DIALIZED POST MRI FOR 3 CONSECUTIVE DAYS TO CLEAR
GADOLINIUM CONTRAST
NEURO INPUT TAKEN
STARTED EMPERICALLY ON ACYCLOVIR (AWAITING HSV PCR)
AUTOIMMUNE WORK UP SENT TO RULE OUT AUTOIMMUNE
ENCEPHALITIS
STARTED ON INJ SOLUMEDROL 500MG OD FOR 3 DAYS
IMPROVED OVER NEXT 2 DAYS GCS 14/15 BUT IRRITABLE AND WITH
ON AND OFF SPELLS OF DROWSINESS
19. DROPPED HB ? GI BLEED AS WAS ON DUAL ANTI PLATELLATES
STEROIDS
STOOL OCCULT BLOOD POSITIVE
GASTRO TAKEN ON BOARD , ADVICED OMEPRAZOLE INFUSION, HB
MONITORING AND BLOOD TRANSFUSION.
WAS DEEMED VERY HIGH RISK FOR UPPER GI ENDOSCOPY
WAS MANNAGED CONSERVATIVELY
HB REMAINED STABLE
NOW AMILY AGREED FOR REPEAT LP ON 6 / 10/19
20.
21. CONTINUED ON ANTIVIRALS AND PREVIOUS ANTIBIOTICS AFTER
DISCUSSING WITH NEUROLOGY TEAM
DEVELOPED RT ARM BLISTERING WOUND . SUSPICIOUS OF INFECTION
WITH SKIN AND CNS INFECTION MADE AND ID TAKEN ON BOARD .
ADVICED US DOPPLER ARM WHICH SHOWED LOCAL EDEMA ONLY.
LOCAL ANTIBIOTICS AND MGSO4 DRESSING APPLIED AFTER
CONSULTING GENERAL SURGERY.
THE WOUND HEALED OVER TIME.
22. 10/10/19
PATIENT AGAIN BECAME DROWSY TLC 10 UREA 29 NA 142
AMPICILLIN AND CEFTRIAXONE STOPPED AFTER 14 DAYS. NOW TAKEN ON
MEROPENEM ALONG WITH ACYLOVIR AND VANCOMYCIN
EEG REPEAT ENCEPHALOPATHY
IMPRESSION OF DRUG INDUCED ENCEPHALOPATHY MADE( ANTI EPILEPTICS
INDUCED) AND PATIENT DIALIZED.
IMPROVED POST DIALYSIS GCS 14/15.
STARTED ON ORAL PRESDNISOLONE BY NEUROLOGY AND ORAL LERRACE
SHIFTED OUT OF MICU ON 14 /10/ 19
LINEZOLID TAKEN ON BOARD IN PLACE OF VANCOMYCIN
23. 15/10/19
WAS PLANNED FOR DISCHARGE
HAD AN EPISODE OF MALENA AND DROP IN HB
BLOOD TRANSFUSED AND GASTRO TAKEN ON BOARD.
OGD DONE ON 17/10/19 SEVERE EROSIVE PANGASTRITIS AND
DUODENITIS
AGAIN STARTED HAVING FEVER SPIKES
COLISTIN TAKEN ON BOARD ALONG WITH LINEZOLID AND
MEROPENEM. PANCULTURES SENT.
FEVER IMPROVED. NO MORE MALENA. HB STATIC
NG REMOVED OVER NEXT FEW DAYS AND ORALLY ALLOWED
24. 18/10/19
AGAIN HAD FEVER 101 F DROWSY RT LEG SWELLING
US DOPPLER FOR DVT NEG TLC 16.6
LERRACE AND LINEZOLID STOPPED
TAKEN ON INJ TIGECYCLIN ALONG WITH MERPENEM. COLISTIN DOSE
ADJUSTED. ACYCLPOVIR STOPPED
DIALIZED TO REMOVE DRUG EFFECTS
AWAITED CULTURES NEGATIVE
SPUTUM CS YEASTS. INJ DIFLUCAN STARTED.
25. 21/10/19
IMPROVED CLINICALLY
AWAKE FOLLOWING COMMANDS.
AFEBRILE.
NG RETAINED FOR NOW FOR POOR INTAKE AND MILD ASPIRATION
SYMPTOMS.
MOBILIZED OUT OF BED WITH SUPPORT.
DIALIZED AS ROUTINE.
1 PCV WAS TRANSFUSED DURING DIALYSIS.
26. RECEIVED POST DIALYSIS IN WARD AT 8 PM.
BP 130/70 WITHOUT SUPPORT
SPO2 96% RR 22 AFEBRILE PULSE 80/MIN.
WAS COMMUNICATING WITH FAMILY.
DISCHARGED WITH NG FEEDING AND HOME PHYSIOTHERAPY AND
FOLLOW UP IN NEXT HDX ( 2 DAYS LATER).
27. NEXT MORNING CAME BROUGHT DEAD IN ER
ACCORDING TO FAMILY WAS HYPOTENSIVE AT HOME AND LOOKING
ILL.
VOMITED.
RETAINED AT HOME AND CAME WHEN UNMANNAGEABLE AT HOME.
28. LATER HER HUSBAND COMPLAINED THAT
1. SHE WAS DISCHARGED PREMATURELY WITH DECREASING BP
2. PAMPER WAS NOT CHANGED
3. NOT VISITED BY DOCTOR FOR 6 HRS
NO DOCUMENTATION OF ANY CALL TO PHYSICIAN WAS PRESENT
LAST DOCUMENTED BP 130/80
FAMILY TOOK THE PATIENT HOME WITHOUT ASKING TO RETAIN.
29. HOSPITAL STAY SUMMARY
ADMITTED ON 26/ 9/19 IN MICU SHIFTED TO STEP DOWN UNIT ON
28/9/19
SHIFTED TO WARD ON 30/9/19
RESHIFTED TO MICU ON 5/10/19 . REMAINED THERE TILL14/10/19
SHIFTED TO WARD ON 14TH AND REMAINED THERE TILL DISCHARGE
ON 21ST OCTOBER 2019.
ALL CULTURES NEGATIVE BUT FOR FIRST BLOOD CS WHICH HAD
STAPH AUREUS SENSITIVE TO CLOXACILLIN
