tokens: 596437842 CTMC 63056604 547591 02/08/1991 12:00:00 AM Discharge Summary Signed DIS Admission Date : 02/08/1991 Report Status : Signed Discharge Date : 02/18/1991 DISCHARGE DIAGNOSES : 1) ACQUIRED IMMUNODEFICIENCY SYNDROME . 2) PNEUMOCYSTIS CARINII PNEUMONIA . 3) ADULT RESPIRATORY DISTRESS SYNDROME . HISTORY OF PRESENT ILLNESS : Mr. Breutzfarstxei is a 30 year old man with recently diagnosed acquired immunodeficiency syndrome and Pneumocystis carinii pneumonia who presented with pneumonia , developed adult respiratory distress syndrome , and died in the hospital after failed efforts of ventilatory support . Mr. Breutzfarstxei was recently diagnosed with acquired immunodeficiency syndrome when he had Pneumocystis carinii pneumonia on 01/17/91 . He was admitted to the Retelk County Medical Center at that time and was treated with Bactrim and steroids . He was actually intubated and underwent bronchoscopy where the diagnosis was made with a positive toluidine blue study . He initially did well after extubation and completed approximately two weeks of Bactrim and a steroid taper . At discharge after about two weeks post-extubation , he had an O2 saturation of approximately 95% on room air . He was seen by Dr. Seen and Dr. Seen as an out-patient . On 02/06/91 , he was seen in FLFDMC and at that point , his temperature was noted to be 101.4 and he had malaise and diarrhea . He was evaluated in the Emergency Room . At that time , his oxygen saturation was only 90% on room air and his chest X-Ray showed no change . Cultures were taken and he was sent out . On 02/08/91 , the patient called Dr. Seen because of increased shortness of breath and malaise . He was seen in FLFDMC where he was noted to have jaundice and newly palpable liver edge . Review of liver function tests revealed a cholestatic picture which was not previously found and it was felt that this was secondary to the Bactrim which had been recently stopped anyway . His oxygen saturation at that time was only 86% on room air and he was admitted . PAST MEDICAL HISTORY : 1) HIV positive with a CD4 count of 74 . 2) Recent PCP . 3) Status post right elbow surgery . 4) Venereal disease history . 5) PPD anergic . The patient &apos;s HIV risk factors include history of intravenous drug abuse , prostitution , and a former prisoner . PHYSICAL EXAMINATION : On presentation , the patient was a young appearing Hispanic male in mild respiratory distress with a blood pressure of 140/90 , heart rate 120 , respirations 32 , and temperature 101 . SKIN : Jaundiced . HEENT : Revealed icteric sclerae , the oropharynx with extensive thrush , and an ulcer under his tongue . NECK : He had no cervical adenopathy and his neck was supple . LUNGS : Had tubular breath sounds especially in the lower lung fields . CARDIAC : Showed regular rate and rhythm without murmurs , rubs , or gallops . There was no costovertebral angle tenderness . ABDOMEN : Soft with bowel sounds and there was mid epigastric and right upper quadrant tenderness . His liver was 10 cm and was felt three finger breadths below the costal margin . His spleen was not palpable . RECTAL : He had guaiac positive stools . EXTREMITIES : Unremarkable . GENITOURINARY : His penis had a 1/2 cm ulcer with yellowish discharge . NEUROLOGICAL : Non-focal . LABORATORY EXAMINATION : On admission , white count was 7.2 with 57% neutrophils , 40% lymphocytes , l mononuclear cell , and 1.6 eosinophils . PT was 12.6 and PTT was 29 . Sodium was 133 , potassium was 4.2 , chloride 100 , CO2 19 , BUN 21 , creatinine 1.2 , and glucose 122 . ALT was 181 , AST was 156 , LDH was 336 , alkaline phosphatase was 214 , and bilirubin was 12.7 total . ( On 02/06 , his bilirubin had been 7.2 with 6 direct ) . His arterial blood gas on 50% was pO2 92 , pCO2 24 , and pH 7.46 . His chest X-Ray showed bilateral nodular infiltrates . HOSPITAL COURSE : The patient was admitted for work-up of his cholestatic jaundice picture along with work-up for his pulmonary process and treatment of both . In terms of pulmonary function , it was felt that one possibility was that the patient was a Bactrim failure for PCP although this was unusual . He was started on Pentamidine , especially in light of the fact that it was felt that his liver function tests were due possibly to Bactrim . The patient was also covered with Erythromycin and Gentamicin for coverage of community acquired pneumonias and gram negative rods . He was given supplemental oxygen . In terms of his liver abnormalities , it was felt that viral hepatitis was in the differential as well as several opportunistic infections of the liver but also was felt that Bactrim could be a cause of these abnormalities . Titers for CMV and Epstein-Barr virus were sent and a titer for toxoplasma was sent . Stool was sent for ova and parasites . Gastrointestinal was consulted . Initially , the patient did well in terms of his pre-status and required less oxygen . However , on 02/10/91 , his respiratory rate increased and his oxygen saturation decreased . Actually in reviewing the records at this point , it appears that Pentamidine was not started initially so on the antibiotics of Erythromycin and Gentamicin , the patient &apos;s respiratory status worsened and his LDH climbed so he began Pentamidine on 02/10/91 . On 02/11/91 , the patient again appeared more comfortable this time with 50% facemask but then required more oxygen , dropped his O2 saturations , and was intubated on 02/11/91 . He was transferred to the Intensive Care Unit on 12/12/90 on Gentamicin , Vancomycin , Pentamidine , and Prednisone . Also of note at that point , hepatitis C virus serologies had come back positive . However , at this point , his liver function test abnormalities appeared more consistent with a cholestatic picture with his direct bilirubin being 12.1 and total being 14.1 . The patient &apos;s abdominal CT scan showed no liver disease and no obstruction . The patient &apos;s liver function tests appeared to improve . The patient &apos;s penile ulcer was cultured and grew positive herpes simplex virus and the patient was started on Acyclovir . On 02/13/91 , the patient had a bronchoalveolar lavage performed which showed a toluidine blue with many pneumocysts noted . No other cultures grew out and the patient &apos;s clinical status deteriorated . The patient required 100% oxygen to maintain adequate oxygen saturations on the ventilator . He required elevated ventilatory pressures with PIPS often above 60 . Fortunately , no evidence of baratroma was ever discerned . However , the patient &apos;s respiratory status continued to decline and we were unable to maintain oxygen saturations above 80% even using reverse I to E ventilation , paralysis , sedation , and other modes of ventilation . Patient underwent liver biopsy on 02/16/91 and the results of this were pending when the patient died . The patient actually developed decreasing counts with white count as low as 1.75 , hematocrit as low as 26 , and platelets as low as 68 noted on 02/15/91 . These were supported with blood products and Hematology was consulted . They felt that it was most likely secondary to Bactrim and these actually were getting better when the patient died . Bone marrow biopsy was not attempted . Discussions were begun with the family regarding limits of supportive care . Due to continued worsening pulmonary status and an overall grim prognosis , the family decided , in consultation with the Medical Team , to withdraw ventilatory support . This was done on the evening of 02/18/91 . Patient expired after the endotracheal tube was withdrawn at 6:40 p.m. DISPOSITION : The patient died in hospital . An autopsy will be performed . An autopsy was performed as per the family &apos;s wishes . WE221/9850 TAKO C. INSKE , M.D. , PH. JT2 FF2 D : 02/18/91 Batch : 8600 Report : V7238B57 T : 02/20/91 Dicatated By : LATO L. TIKFREIERM , M.D. cc : 1. LERMA N. WYNBRANTESXELL , M.D. 2. ANA V. A , M.D. 3. DALLI A. SEEN , M.D 4. ARC N. SEEN , M.D.