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Present Situation

May 18th to September 13th  2001

 

      From May 18, due to the signs of consciousness decline and increasing Ascitis, the patient has been hospitalized for the third time. The patient clinical situation during this period is summarized in below:

1.      In the first fifteen days since there were suspicions of Phenytoin toxicity, this drug was replaced with Sodium Valproate but still the level of consciousness declined more.

2.       Accumulation of Ascitis fluid in abdominal become more severe.

3.      The body temperature, which was between 37o-38o c during the previous month, increased to 38 o -39.5 o.

4.      In purpose to lower the burden on liver, all the anticonvulsant drugs were discontinued (Sodium Valproate & Lamictal). In this stage the thesis of liver Encephalopathy, as the cause of consciousness disorder became under consideration.

5.      At last, for managing the Ascitis, 3200 cc of Ascitis Fluid were tapped. Lab results & cytology of Ascitis Fluid proved no abnormalities.

6.      To diagnose the origin of Ascitis, several Color Doppler, Venography, and Gamma Scan were taken and LFT’s were all normal.

7.      After tapping to dry the ascitis fluid, it did not recurred and together with prescribing of Dexametazone for a short period, the consciousness level increased up to a level that the patient was able to speak very short and logical sentences.  

8.      Due to diagnosing Fungus in patient’s mouth and stomach, the patient underwent taking Fluconazole for 15 days.

9.      At June 20, the patient faced a generalized seizure (Status Epilepticus), which led him to ICU, and the seizures were controlled with Diazepam and Phenytoin.

10.  Again, the consciousness level declined and the patient stomach began minor bleeding because of taking Ibuprofen (for lowering the fever). 

11.  Bleeding was managed but chronic fecal impaction and paralytic Illeus worsened the patient situation.

12.  Disorders in GI tract led the patient to NPO situation and feeding by TPM though CPV line.

13.   Fecal Impaction was cured with daily numerous enemas but after feeding the patient by mouth, because of persisting Illeus and sever distention of abdominal, the patient began vomiting which caused aspiration and lunge difficulties that still is under medication with ventilatory system.

14.  The brain CT-Scans taken from patient at June 29,2001 (CT-Scan10 and CT-Scan11) proves that the shunt is incompetent and showed signs of inflated ventricles and chronic hydrocephalus. Patient CSF was taken for bacterial and viral study and because of WBC’s seen in it, it underwent a cyto-pathologic study. Bacterial and Viral Studies of CSF were all normal and Cytology showed some reactional cells caused by either seizure or hydrocephalus.  

15.  For managing the incompetancy of shunt and lowering the pressure, the shunt reservoir was pumped daily from outside, which after five days were deflated a little (10 Jul, 2001 CT-Scan12, CT-Scan13) and after pumping about two weeks the right ventricle completely collapsed and therefore pumping the shunt reservoir was discontinued (22 Jul, 2001 CT-Scan14, CT-Scan15). The serial CT-Scans taken at July 26th & 30th 2001 showed that the so-called ventricle is gradually being refilled with CSF, meanwhile the left ventricle has been deflated a little. 

16.  The serial CT-Scans taken at 22 July (CT-Scan14, CT-Scan15), 26 July (CT-Scan16, CT-Scan17), 30 July (CT-Scan18, CT-Scan19) and 7 August (CT-Scan20, CT-Scan21) for monitoring the brain development, respectively showed:

·        Gradual and very slow refilling of right ventricle

·        Midline shift of left ventricle

·        Ventriculits(the hyper dense margins of ventricle systems) which along with more decline in consciousness led to beginning of Anti-Tuberculin medication

17.  Form August 7th the patient situation worsened, which can be summarized as below:

·        Appearance of ARDS signs in lunges which led to tracostomy

·        Hematological disorders, specially in HGB and PLT continuous decreased

·         Steeps decline in blood pressure and kidneys disorder because of discontinuing of the Dexametasone, which was managed with Hydrocortizone

·        Electrolytic disorders (Sodium increased to 170), which so far has been lowered down to 155

18.  From August 20, the patient fall into a deep coma, with a GCS about four or five, along with a very weak reflection in right eye and somehow more in left eye. The CT-Scan taken at August 22 (CT-Scan22, CT-Scan23) shows a hemorrhage in left hemisphere, which the medical team believes that it is the cause of PLT decrease to 33000 a week later.

19.  The patient neurosurgeon measured the pressure of the left ventricle by needling from outside and found out that the pressure is at a normal level and the CSF sample was sent to laboratory.

20.  The medical team, so far, has not been able to diagnosing the reason of new situation and therefore there is no medical plan for the patient.  

21.  Four days after installing external shunt and one day after clamping the internal shunt (30-8-2001).CT-Scan24, CT-Scan25

22.  10 days after installing external shunt and two days after clamping it (2-9-2001). CT-Scan26, CT-Scan27

23.    One day after installing the external shunt in the left ventricle (8-9-2001). CT-Scan28,CT-Scan29

24.   Three days after removal off both shunts (internal and external) and inflation of ventricular system (12-9-2001).CT-Scan30,CT-Scan31

 

 

 

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