Case Conference
November 20th, 2012
Jiten Patel & Alisha Lacour
Chief Complaint

 Headache X 1 week
HPI

 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 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 Continued

 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

 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

 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
Past Medical History

 Kidney Stones
 ESWL 2011
 COPD
Past Surgical History

 Cystolithotomy 2005
Medications

 Ciprofloxicin 500mg PO BID
 Oxycodone-Acetaminophin 5-325mg PO Q4-6 hours
 Tamsulosin 0.4mg PO QDay
Allergies

 Penicillin – swelling of extremities
Family History

 Father passed away from cardiac disease – 70’s
 Mother passed away from lung cancer – 60’s
 Siblings healthy
 Several family members with kidney stones
Social History

 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
Health Maintenance

 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
ROS

 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
Physical Exam

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

 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

 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




Labs OSH (Day prior)

134
3.8
98
13
29 0.93
(24-32)
Ca 8.2 (8.4-10.3)
Mg 1.6 P 2.1
131
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
(4.5-11.0) 18.0
13.3
93
224
40.0
13.3
N 92 L 4 M 3
UA:
Sg
pH
Prot
Glu
Ket
Bili
Blood
Nitrite
Urobiligin
LE
1.010
7.0
25
Neg
Neg
Neg
25
Pos
4.0
500
RBC
WBC
Sq
Bact
Casts
6-10
>100
20-100
Many
3-5
Hyaline
Labs Admit

134
102 13
4.0
26
0.9
150
(4.5-11.0) 13.9
93
224
36.2
13.3
N 96 L 3 M 1
Ca 8.5 Mg 1.6 P 2.1
Blood Cultures
drawn
12.6
UA:
Sg
pH
Prot
Glu
Ket
Bili
Blood
Nitrite
Urobil
LE
1.011
7.0
25
Neg
Neg
Neg
25
Neg
8.0
500
RBC
WBC
Sq
Bact
Casts
0-2
3-5
1-2
negative
0
CT Head 2/18

CT Head 2/18

CT Head 2/18

CTA Brain (2/19)

CTA Brain (2/19)

CT Brain (2/24)

CT Brain (2/24)

Labs

 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
Gram Stain

Gram Stain

Gram Stain

Hospital Course

 She was admitted:
 Placed in respiratory isolation
 Treated with:
 Dexamethasone
 Vancomycin
 Imipenem due to her penicillin allergy.
 Her headache improved.
Hospital Coarse

 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
MRI Brain

MRI Brain

MRI Brain

MRI Brain

MRI Brain

MRI Brain

MRI Brain

MRI Brain

MRI Brain

MRI Brain

MRI Brain

MRA Brain

MRA Brain

Hospital Course

 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 Coarse

 Repeat LP




Clear
Glu 37
Pro 64
WBC 130
 N 9% L 89% M 2%
 RBC 0
 Gram Stain:
 No Organisms
Hospital Course

 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

Hospital Day 7
Became more lethargic
On call intern notified
 Evaluated patient, noted papilledema
 STAT CT head Ordered
CT Brain

CT Brain

CT Brain

CT Brain

CT Brain

CT Brain

CT Brain

Hospital Course

 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

Thank You