Sunday, June 23, 2013

Mystery Case

So I thought of titling this case of the week but I don’t think I will be doing this regularly – this is case that has mystified the internal medicine service so if you think you have an answer please let me know. For all my non-medical friends sorry if this is boring/confusing I will get an update more about life soon, I do ask that you hold up this young man in prayer.  Also as I would like some feedback soon I have posted this post before my editor reviewed it I apologize for any grammar/spelling errors.

I got called to meet Kibet (not his real name) last week, a 20 something year old man. He had come into casualty (Emergency Room) talking and complaining of difficulty swallowing and shortness of breath. Over his time in casualty he deteriorated and became obtunded. When I was called to see him he was unconscious GCS – 3 and his RR was 10. We started bagging and intubated him. The intubation took some time as we were teaching the interns by the time we got the tube in his GCS had improved to maybe a 6. By the time we got him to ICU we had to give him Versed to keep him calm to keep the tube in. I set him up on the vent (Servo 900C). He was happier on the vent and no longer required versed. I turned him to pressure support but he had no Respiratory drive, so we left him on A/C. After some time on the vent An ABG was done with a pH of 7.56, PaCO2 30, HCO3- of 32 (I’m pulling it from memory so it’s not exact) We left him on the vent overnight and the next morning he was triggering the vent some so I placed him on SIMV hoping to wean him some. An upper GI Scope was done which was normal as was a Lumbar puncture which showed increased WBC – so possible Meningitis. We started treatment for bacterial meningitis.
The next morning he was triggering the vent better and we extubated him by mid-morning. A blood gas done a few hours later was pH 7.46, PaCO2 40 and HCO3 of 28 (again from memory). Also throughout his whole time he has not been hypoxic/requiring O2.
The patient was quite awake and co-operative both on and off the vent. Once he was off the vent  we were able to get a better history, he has had trouble swallowing for about 3 months – which is not a normal time frame for bacterial meningitis so we are thinking maybe TB meningitis??? He has not been working the past few months as he has been weaker than normal however he had reasonable leg/arm strength.
The next few days myself and the medical team expected him to get confused and hypercarbic again. As we think something neuromuscular is going on. The patient did well. I would find him in a chair, having coherent conversations and no signs of Resp. distress. We did not do serial ABG’s as they are about a day or 2 wage here.
However this morning I got called out of bed – he has done it again and is obtunded again. We grab another ABG pH 7.15, PaCO2 – 104, HCO3 – 34. Rather than intubate him again we place him on bipap. Within 45 min he is awake and doing well. This time as he was in ICU we were able to better watch his deterioration – apparently his Blood pressure is very positional, he is comfortable sitting straight up with his head arched back and with his legs bent underneath him.
So now he is on and off BiPap I talked to him this afternoon and the bipap his helping – however what is the problem. Is it treatable? I can’t send him home on Bipap as I don’t have enough machines. Anybody have any ideas – feel free to comment on this blog or e-mail/facebook me. Please also hold up this man in prayer.


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