Quest for Camelot

Patient is a 74 year old female with long history of severe osteoporosis and osteoarthritis. She has never smoked and her SATs were normally in the upper nineties before current illness. She under went partial shoulder replacement surgery on 2 April. The shoulder became dislocated during rehab and a second surgery was performed to correct the dislocation on 21 April. She remained in sling with little to no PT until 20 June. Very mild PT was begun at her retirement home by a home health care company. The home health care nurse noted her SATs were often in the lows nineties. Following a routine doctors visit she complained of having chest pain when breathing and shortness of breath about a half hour after returning home.

She was transported to the ER and diagnosed with pericarditis and admitted to the hospital Wed 8 July. She was placed on 2 liters of O2 via cannula. She had a couple of episodes of atrial fibrillation Wed night and Thursday night during which her heart rate went to approximately 120 bpm. She was placed on medication to reduce her heart rate and converted to normal sinus rhythm both times. The heart rate medication IV was discontinued by Friday morning and she seemed to be improving on Friday. She was able to get out of bed and use the bedside latrine with little or no help. She was alert and able to feed her self.

Saturday afternoon she went into atrial fibrillation again and this time her heart rate went to 180 bpm. The IV used to control heart rate was restarted and she converted back to sinus rhythm. Her breathing seems to ave steadily gotten worse following this incident. First she went from the cannula at 2 liters of O2 to a mask at full O2 and then to BiPAP and is now on a ventilator in ICU.

Cardiac echo tests have indicated heart is strong and no sign of valve problems. The fluid in the pericardium is now minimal. Her BP has been generally low in the 90/45 range with fluctuations (probably due to medications and sleep cycle changes).

Family History:
Mother deceased at age 38 cause leukemia. Father deceased age 68 lung cancer detected when he experience atrial-fib episode. Grandmother certain history of tuberculosis or Lupus. One maternal uncle died with Lupus. One first cousin with Lupus currently living. Brother with Rheumatoid Arthritis.

The doctors have told me her RH factor and ANA are both negative although I have not seen those test results. Her white count is normal and thus a infection is not thought to be the cause; however she has been treated with first Bacrum DS and is now on a Levaquin IV.

Her lungs seem to be filling with fluid and getting worse as time goes on.

wbcnormal8.4

The following are the test results which are outside of normal range:

rbclow2.63
hgblow8.0
hctlow23.6
rdwhigh15.8
Granulocyteshigh88
Lymphslow5
Absol Lymphslow0.4
D DimerQuanthigh0.76
NAlow126
Chloridelow93
Bunhigh54
Creatininehigh1.6
Bun/Creathigh34
GFR est AAlow47
GFR est AAAlow39
Calciumlow8
GPTlow22
Anion Gaplow4
C React Prothigh8.8

Any thoughts on possible underlying causes or suggestions of tests which should be run would be greatly appreciated!
Yes she has had three chest xrays so far. They have indicated more fluid in the lungs each time. Actually I have not heard the results of yesterdays xray yet.

Thanks for your suggestions I will ask her doctors about that today!
She had no history of chest pain prior to the onset last week. Unfortunately she was unable to lie on the table for VQ scan due to her spinal curvature as a result of spinal fractures from osteoporosis.
I asked the doctor about pulmonary embolism. They did perform a CT pulmonary angiogram which revealed no abnormality. That doctor now says his best opinion is ARDS but was still not able to define the underlying cause. They are treating with anti-biotics as I said earlier. The doctor says that the signs of inflammation and anemia would tend to indicate a possible chronic infection. I asked again about autoimmune causes especially since Lupus and RA are prevalent in other family members. The doctor says both rheumatoid factor and ANA are negative; but one doctor made mention of something funny with test results where RF was positive one day and then negative the next. I still have not gotten a good answer about that today I will demand to see the tests results myself.
One other thought comes to mind since her hemoglobin was low she was given a transfusion on either Thursday or Friday last week. It was on the Saturday following that when she appeared to take a nose dive from what was an improving condition. Perhaps some transfusion reaction is the cause of the turn for the worse????

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i would definatley be looking towards pulmonary embolism.

raised d dimer, prev h/o chest pain, recent surgery,she needs a vq scan. has she had a plain chest xray?

deborah h | Jul 15, 2009

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I really hope I never have you for a doctor.
jmac | Jul 15, 2009

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