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

A Not So Simple UTI

Case ConferenceNovember 20th, 2012

Jiten Patel & Alisha Lacour

Headache X 1 week

Chief Complaint

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

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

HPI Continued

Kidney Stones

ESWL 2011 COPD

Past Medical History

Cystolithotomy 2005

Past Surgical History

Ciprofloxicin 500mg PO BID Oxycodone-Acetaminophin 5-325mg PO Q4-6

hours Tamsulosin 0.4mg PO QDay

Medications

Penicillin – swelling of extremities

Allergies

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

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

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

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

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

Physical Exam

Labs OSH (Day prior)

134 98 133.8 29 0.93 (24-32)

131

Ca 8.2 (8.4-10.3) Mg 1.6 P 2.1

TP Alb TB AST ALT ALP7.2 2.7 1.6 20 20 61 (3.5-5.0)(<1.3)

Received dose of Gentamicin

UA:SgpHProtGluKetBiliBloodNitriteUrobiliginLE

1.0107.025NegNegNeg25Pos4.0500

RBC 6-10 WBC >100Sq 20-100Bact ManyCasts 3-5 Hyaline

(4.5-11.0) 18.0 224

13.3

40.0

N 92 L 4 M 3

93

13.3

Labs Admit

134 102 134.0 26 0.9

150

Ca 8.5 Mg 1.6 P 2.1

Blood Cultures drawn

UA:SgpHProtGluKetBiliBloodNitriteUrobilLE

1.0117.025NegNegNeg25Neg8.0500

RBC 0-2 WBC 3-5Sq 1-2BactnegativeCasts 0

(4.5-11.0) 13.9 224

12.6

36.2

N 96 L 3 M 1

93

13.3

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)

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

Gram Stain

Gram Stain

Gram Stain

She was admitted:

Placed in respiratory isolation Treated with:

Dexamethasone Vancomycin Imipenem due to her penicillin allergy.

Her headache improved.

Hospital Course

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

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

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

Repeat LP

Clear Glu 37 Pro 64 WBC 130

N 9% L 89% M 2% RBC 0 Gram Stain:

No Organisms

Hospital Coarse

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

Hospital Course

CT Brain

CT Brain

CT Brain

CT Brain

CT Brain

CT Brain

CT Brain

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

Thank You