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Washington University Experience | VASCULAR | Infarct, watershed | 10A0 Case 10 History
Case 10 History ---- The patient was a 73 year old male nursing home resident, with a history of multiple strokes, intermittent atrial fibrillation, S/P inferior MI, stage 1A nodular sclerotic Hodgkin's disease, IDDM, HTN and S/P left endarterectomy. He was admitted directly to the ER when rectal bleeding was noted on 10/13 by family. At that time he was noted to be lethargic, oriented only to his name and his best response was "yeah". The patient was febrile to 38.8oC and no further details were obtainable. Apparently the patient suffered 4 strokes in '81,88 and '90 among which left parietal and left occipital lesions were expected. Upon presentation to the ER the patient was a cachectic man with episodic moaning. The right small toe and the right lateral foot were gangrenous and the left toes were cyanotic. On admission, he was lethargic, with no response to pain. Cranial nerves were noted to be grossly intact with pupils reactive bilaterally with doll’s eyes. Reflexes were 2+ and symmetric throughout, the toes were downgoing and cerebellar evaluation was not performed. Initial laboratory evaluations disclosed a hematocrit of 36.2, hemoglobin 12, white cell count 13.5, BUN 91, and creatinine 4.5. The patient was admitted to the ICU for further care. His hospital course included hypernatremia (151) which resolved and by worsening renal failure. Blood and urine cultures were negative. He continued to be lethargic. The patient was to be discharged to his nursing home but was found pulseless by the nursing staff.
