Morbidity and Mortality Conference

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Morbidity and MortalityConference

• Lisa Leinau
• March 13, 2002

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History

• 55 year old woman
• Flu-like symptoms -- fatigue, headache, nausea,
  difficulty concentrating
• Developed disorientation
• Sodium 107
• CBC, liver enzymes, calcium, magnesium,
  phosphate, cortisol TSH normal
• CT head normal
• Diagnosis SIADH
• Hospitalized and hyponatremia corrected with
  fluid restriction and hypertonic saline

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Continuing history

• Referred to neurology clinic at DHMC
• CT head reviewed by neurologist normal
• Also then referred to nephrology clinic at DHMC

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Past medical history

• Breast cancer
• S/p right radical mastectomy, 1983
• multiple positive nodes
• Declined radiation
• Treated with chemotherapy
• Postmenopausal since time of chemotherapy
• Para 4
• Last birth caesarian section
• H/o chest pain
• By patients report, normal exercise stress test
• H/o heart murmur
• Anxiety/insomnia

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Social history

• Tobacco 1-2 ppd since age 13
• No alcohol
• Employed assembling electrical parts
• Widowed three years ago
• Four adult children
• 19 y.o. daughter who is cognitively/socially
  delayed lived with her patient was primary
  caregiver for her daughters two children

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Additional history

• Amnesia for acute events around hospitalization
• Does not yet feel back to normal
• No headache
• Vision hazy since hospitalization, but
  improving
• Nausea resolved
• No fevers, chills, night sweats
• Appetite unchanged sleep unchanged
• Bowel and bladder habits unchanged
• No chest pain, palpitations
• No dyspnea, no cough, no sputum, no hemoptysis
• No seizure, no h/o TIA or CVA
• No weakness or paresthesia

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Family history

• Mother alive, age 78
• Diabetes mellitus, type 2
• s/p CABG
• Father died age 52
• complications of alcoholism
• Youngest of three brothers died from AIDS
• Four sisters alive and well
• No other metabolic disease no malignancy

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Medications

• Salt tablets 2 daily
• Alprazolam 0.5mg PO QHS PRN rarely used
• Fluid restriction 2 to 3 cups per day

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Physical exam

• Alert, cooperative, pleasant, affect initially
  anxious
• BP 160/90 HR 80 O2sat 97 RA wt 156 lbs
• Speech slightly slow, but within normal limits
  no dysphasia
• HEENT sclera and conjunctiva clear, vision and
  visual fields normal, gaze conjugate, PERRLA,
  EOMI, no pathologic nystagmus, fundi without
  papilledema or hemorrhages, tongue and palate
  movement normal, uvula midline, facial strength
  and sensation normal, no adenopathy

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Physical exam continued

• Heart regular rate with minimal ectopy I-II/VI
  systolic ejection murmur left upper sternal
  border no rubs, gallops
• Chest s/p mastectomy on right
• Lungs clear with good excursion
• Abdomen soft, nontender, normal bowel sounds, no
  hepatomegaly
• pulses 2 radial, dorsalis pedis, posterior
  tibial
• no edema no cyanosis or clubbing
• Skin without rashes, nail beds normal
• No synovitis or joint deformity

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Physical exam continued

• MMSE 29/30 with difficulty drawing the figure
• Strength and tone normal, no pronator drift
• No tremor, no asterixis
• Fine finger coordination within normal limits
• Reflexes diffusely hypoactive, no Babinski sign
• Mild distal sensory neuropathy
• Position sense preserved
• Graphesthesia normal
• Normal finger to nose and heel to shin movement
• Gait, including tandem walking, normal

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Labs
14.4 129 90 14 8.7 356 94 40 4.5 26 0.
6 Ca 9.8 Mg 0.82 Phos
4.4 Urinalysis sg 1.019, pH 5, sq epi 7, no
WBC, RBC, glucose, protein Random sodium 182,
potassium 69, chloride 235 urine osmolality 871
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Labs continued
Tbili 0.4, Dbili 0.1, AlkP 112, GGT 26, AST 18,
ALT 24 Cholesterol 193, Trig 70 ESR
15 Angiotensin converting enzyme 18 TSH 0.72,
T4 9.3, T3Q 114 Cortisol 9.8 B12 544 Syphilis
IgG negative Rheumatoid factor lt20 ANA positive,
titer 180 speckled pattern Prolactin
6.4 SPEP no M-spike Mammogram left breast
Category 1
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• Chest x-ray
• lungs clear without nodules or consolidation
• heart and mediastinum normal
• MRI brain
• findings consistent with demyelination in the
  central pons
• non-specific periventricular white matter changes
• CT chest, abdomen, pelvis
• Poorly defined 1cm spiculated opacity in anterior
  left apex
• Liver, spleen, pancreas, adrenals, gallbladder,
  kidneys, uterus and adnexa normal

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Neurology follow-up

• Headaches
• Aches and pains, especially in back
• Abdominal bloating
• Dysuria
• Abdomen diffusely tender and distended on exam
• No changes in neurologic exam
• KUB large amount of stool, no obstruction or ileus

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Labs
13.5 138 102 26 21.1 98 162 39.2 3.6 23
0.4 59 N /8 B /18 L /9 M /0 E /4 Meta /2
Myelo 2 nucleated red blood cells Tbili 0.9,
Dbili 0.3, AlkP 236, AST 73, ALT 193 Ca 9.4,
Albumin 3.8, TP 7.4 urinalysis sg gt1.035, pH 6,
sq epi 1, WBC 1, RBC 168 leuk esterase and
nitrites negative protein 100, glucose
gt1000 sodium 153, potassium 68, chloride 195
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Studies at outside hospital
Amylase 75 RUQ U/S mild diffuse hepatomegaly
no intrahepatic ductal dilatation gall bladder
wall thickening CXR coarse interstitial
markings throughout lungs CT head nonspecific
hypodensity in occipital regions
bilaterally Treated with azithromycin for
possible pneumonia
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DHMC neurology

• Alert, coherent, logical, fully oriented
• essentially blind, distinguishing only light/dark
• Tm 36.5 BP 120/60 HR 50-60 RR 20
• HEENT PERRL, CN II-XII intact, no thyroid
  nodules, no adenopathy, JVP not visible at 45
  degrees
• heart and lungs normal
• abdomen soft, hypoactive bowel sounds,
  distended, mildly tender epigastrum, liver span
  approx 25 cm, palpable 5cm below costal margin
• neuro exam normal except 1 lower extremity
  reflexes

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Admission labs
13.1 PT 14 133 97 23 16.4 69 INR
1.1 206 38.5 PTT 25 3.3 23 0.4 82 N/ 8 B/ 7
L/ 3 M Ca 8 Phos 0.5 4 nucleated red blood
cells ESR 5 Tbili 1.8, Dbili 0.7, AlkP 209,
AST 75, ALT 171 Albumin 3.2 Urinalysis sg
1.031, pH 7, WBC 2, RBC 698 protein 100, glucose
gt1000, ketones 15
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Additional labs
Random urine phosphorous 143.4 PTH 287 Hgb A1C
6.3 Hepatitis B negative Hepatitis C
nonreactive CPK 716 LDH 595 Platelet assoc Ig
negative cosyntropin stim test
85.2 12.9 134 100 23 blood smear 16.2 75 3.3
25 0.5 no schistocytes 36.4 glucose 202 no
spherocytes Dimer 8040 Nucleated RBC PT
14.1 Ca 8.1 INR 1.2 Mg 0.88 PTT 25 Phos 0.5
0.4 0.3 1.3 TT 21
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MRI brain

• Interval development of extensive T2 prolongation
  consistent with vasogenic edema, most marked in
  the occipital lobes, also involving the parietal
  lobes -- consistent with leukoencephalopathy

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• MRI lumbar spine
• diffusely abnormal marrow signal with geographic
  enhancement at each level consistent with
  metastatic neoplasm
• Bone scan
• abnormal patchy radiotracer accumulation in
  mid-thoracic spine, L1, L3, L4 and left sacral ala

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Synaptophysin (), cytokeratin (-) by immunos
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• Bone marrow aspirate
• Cytologic and histologic appearance classic for
  small cell carcinoma
• Unable to perform immunohistochemistry
• Bone marrow biopsy
• Cytokeritin negative ruling out any possibility
  of breast cancer

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Additional labs
24 hour urine collection 25-hydroxy Vit D
6 total volume 900cc (normal range 8-38) total
protein 1.1 gram/TV creatinine 1.14 gram/TV PTH
related protein 0.3 phosphorus 2.2
gram/TV (normal lt1.3) SPEP no M spike
detected uric acid 3.9 Tbili 3.4, Dbili
2.2, AlkP 427, AST 152, ALT 179 ferritin
gt2000 iron 294 TIBC 307 transferrin sat
96 hemachromatosis DNA pending
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Hospital course Day 7
After discussion with patient and her son,
chemotherapy with Etoposide VP-16 and
carboplatin was begun Mental status waxing and
waning during the following days Hypoxic
despite clear lung exam
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Hospital courseDay 11

• Continued abnormal liver enzymes
• Tbili 4.8, Dbili 3.4, AlkP 334, AST 158, ALT 141
• MRI abdomen
• hepatomegaly with fatty infiltration
• multiple patchy opacities in the lungs.

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Hospital course Day 12
Fever 38.9 O2 sat 75 on 50 face mask improved
to 98 with bipap lungs bilateral coarse
rhonchi 10.1 1.2 62 31.0 blood cultures
drawn Piperacillin and tobramycin
begun Dilaudid for comfort Died that evening
with her family present