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Washington University Experience | VASCULAR | Infarct, Tract Degeneration, illustrative case | 2A0 Case 2 History
Case 2 History --- The patient is a 78-year-old woman with a history of left middle cerebral artery infarct (23 years prior to her death), hypertension, and hyperlipidemia. She had a recent admission (12/28 to 01/10) for hypertensive encephalopathy and non-ST elevation myocardial infarction. She was found to have no acute brain infarction or bleeding and was subsequently discharged to a skilled nursing facility. On 01/20, she was brought to the emergency department from the nursing facility following a fall from her chair, reduced mental status and seizure-like activity. She was reported to have 4 days of progressively worsening abdominal pain and headache. At presentation, she had sepsis, acute kidney injury, widened pulse pressure and leukocytosis. Her urine culture was positive for E. Coli. Her head CT did not show any evidence of an intracranial process, only pan-sinusitis. Her chest X-ray was negative for focal consolidation, pleural effusion, or pneumothorax. Her abdomen and pelvis CT suggested aspiration changes in the left lower lobe of the lung and a fluid-filled distal esophagus, mild gallbladder wall thickening, and subtle patchy opacities within the bilateral kidneys which may reflect pyelonephritis. Gallbladder ultrasound showed no evidence of acute cholecystitis. She was started on empiric antibiotics and transferred to the MICU for continued care. In the MICU her mental status and renal function remained poor, and her respiratory status worsened. After discussion with family the patient was intubated. A few minutes following intubation, she became hypotensive requiring vasopressors. She experienced cardiac arrest and was resuscitated following six rounds of advanced cardiac life support. She continued to require high doses of vasopressors. Her family was updated on her worsening critical illness and elected for DNR/DNI. Chest X-ray revealed moderate left pneumothorax with no evidence of rightward mediastinal shift to suggest tension effect. Needle decompression was performed with no improvement in hemodynamics. She remained hypotensive and passed away with her family at her bedside.
