Opinion ID: 1123465
Heading Depth: 1
Heading Rank: 2

Heading: appencix a

Text: September 11, 1986 Mr. Virgil D. Dutt 350 South Center Street Suite 250 Reno, Nevada 89501 Re: Jack Rentnelli Dear Mr. Dutt: We are in receipt of your firm's check and medical records of Jack Rentnelli from St. Mary's Hospital and Santa Barbara Cottage Hospital. As you know, I am a Board-Certified surgeon, fully experienced in the diagnosis and treatment of patients with problems similar to those in this case. Over the past ten years we have reviewed more than twelve thousand medical files to issue opinions regarding malpractice. Associate Director Kevin S. Billings and I have reviewed the records of Jack Rentnelli and have prepared the following confidential Work Product Report for you. Jack Rentnelli, a 63 year old white male, was admitted to St. Mary's Hospital on February 19, 1985 with a 2 week history of headache and a change in personality. The headaches were described as occurring daily, continuously, and generalized with no directly associated symptons. The patient apparently had some change in personality, clumsiness, forgetfulness and some speech problems. He was taking one medication at that time for high blood pressure. Physical examination on admission was essentially normal with the exception of mildly abnormal cerebellar function (eye-hand coordination). Neurological consultation obtained on the day following admission stated an impression of meningitis, exact type unknown. It is noted later that under family history the patient stated that his father was deceased due to tuberculosis. On admission a spinal tap was performed and although pressure readings of the fluid in the spinal column are normally obtained, on that occasion an exact reading was not taken, but there was no obvious increased pressure in the fluid. Spinal fluid analysis demonstrated an abnormally elevated number of white blood cells and protein as well as a decrease in the glucose concentration, all of which are consistent with laboratory findings for tuberculous meningitis. Computerized tomography scan, a computer directed and enhanced x-ray study, revealed enlargement of the spinal fluid filled compartments of the brain, possibly due to normal pressure hydrocephalus. On February 22, 1985 a second lumbar puncture (spinal tap) was performed and again an opening pressure was not obtained due to patient movement. Laboratory analysis of the cerebrospinal fluid sample revealed similar findings to the study done 3 days prior. Chest x-ray revealed paratracheal node calcifications. An infectious disease consultation referred to the x-rays in stating that: Because of the chest calcifications, I agree that this body may have seen the tuberculous organism in the past and certainly, his cerebrospinal fluid (CSF) examination could be consistent with an active case of tuberculous meningitis. Based on the clinical and laboratory findings the patient was started on a regimen of antituberculosis drugs on February 25, 1985. During Mr. Rentnelli's hospital stay he experienced electrolyte imbalances. Electrolytes are chemicals in the blood stream which are necessary for cellular function and metabolism. The chemicals must stay within a specific range or complications will result. Through oral and intravenous fluid therapy the patient's electrolytes were manipulated in an attempt to achieve normal levels. Over the course of the patient's 2 week hospital stay, He underwent a slow but progressive improvement in his overall status. Although he was noted to be quite independent at the time of discharge, there was still some confusion which necessitated someone to care for him 24 hours a day. The patient was discharged on March 3, 1985 with a plan for follow up and on antituberculosis medications. On March 13, 1985 Mr. Rentnelli was admitted to Santa Barbara Cottage Hospital with the chief complaint of headache and mental obtundation. The reason for the admission primarily was because of the unrelenting nature of the patient's headache and relative lack of evidence that the patient is recovering any of his mental acuity. Recent medical history and physical examination findings were unchanged since the previous hospitalization. The initial diagnosis was acute meningioencephalitis, etiology to be determined. Two days after admission a lumbar puncture was performed and finally a cerebrospinal fluid opening pressure of 310 mm. of water was obtained. The record does not state the patient's position while the pressure readings were taken. This is significant because with the patient in the horizontal position the pressure varies from 80 to 200 mm. of water, yet in the sitting position readings of 280 mm. of water are not unlikely. During the spinal tap procedure 22 ml. of cerebrospinal fluid were removed for testing and subsequently the patient reported headache relief. In the progress record, the entry dated March 18, 1985 states: telephone report from lab at St. Mary's Hospital, Reno, this a.m.: spinal fluid cultures showed 3 colonies of acid fast bacilli. These will now be isolated (3 weeks) and sent to state lab and Center for Disease Control for confirmation. Mycobacterium tuberculosis, the microbial which causes tuberculosis, is characterized as one of the agents that are acid fast. [] Additionally, most disease causing Mycobacteria grow unusually slowly and, due to the small amount of spinal fluid cultured, are often difficult to isolate. An infectious disease consultation obtained on March 18th made note of persistently positive PPD. This refers to the purified protein derivative skin test which is strongly sensitive in the diagnosis of tuberculosis. The only reference to reading a PPD skin test is dated March 19, 1985 in the progress record and states: shows only erythema (redness) 9 mm. with no induration (hardness). This could be interpreted as a doubtful positive or possibly a 1 + positive. The department of pathology's assessment revealed a 0 to 5 mm. induration, which can be interpreted as negative. Computerized tomography of the head revealed findings indicative of a communicating hydrocephalus ... whether there is normal pressure or not should be clinically considered. On March 22, 1985 the patient was taken to surgery for a biopsy of a mass and for insertion of a shunt, a valve designed to release cerebrospinal fluid in the event of increased intracranial pressure. The procedure was completed successfully using proper technique and the biopsy specimen was found to be benign. A CT scan completed 3 days after the procedure showed: dilatation of the entire ventricular system persists and may be minimally improved. It is noted in the discharge summary that postoperative the patient developed a right facial palsy which fluctuated in severity since its onset. Etiology is uncertain. It could be simply a coincidence or, result of the intracranial manipulation, or involvement of the seventh nerve by the tuberculous meningitis. Mr. Rentnelli's neurological status and headaches continued to improve until his discharge on March 30, 1985. Clinical manifestations of tuberculous meningitis are usually headache, lethargy, confusion, fever associated with stiff neck and signs of raised intracranial pressure. Mr. Rentnelli clearly demonstrated these findings. From Principles of Neurology, copyright 1981, it states: In most patients with tuberculous meningitis there is evidence of active tuberculosis elsewhere, usually in the lungs and In some patients only inactive pulmonary lesions are found. The patient had a predisposing family history of tuberculosis and suspicious x-ray findings in the lungs. Concerning the apparently negative purified protein derivative skin tests the above cited text cites only 2 of the 35 patients had nonreactive tuberculin tests. Laboratory studies of cerebrospinal fluid in a case of tuberculous meningitis demonstrate an abnormally increased number of white blood cells, elevated protein levels and reduced levels of glucose. As previously mentioned, the patient perfectly conforms to the abnormal laboratory studies in tuberculosis. Although in the records there is suspicion of tubercular bacilli in the cultures, exact isolation of the specific organism is not necessary for the diagnosis and treatment. Once diagnosis is reached based on clinical features and laboratory studies, treatment is instituted at the earliest convenience, since without treatment an invariably fatal outcome occurs within 4 to 8 weeks of the onset. In reference to the increased pressure of the cerebrospinal fluid, it was most likely due to normal pressure hydrocephalus which is a possible sequelae of tubercular meningitis. Upon contracting one of our expert neurosurgical consultants we found that it is within the standard of care to not evaluate cerebrospinal fluid pressure and it was felt that the one month period between the patient's initial admission and the eventual shunt placement would not produce significant brain damage. [] The focus of importance in this case is the correct diagnosis and treatment of an organism which is elusive and difficult to isolate and culture. After thorough review and research we can find no provable negligence in this case. Please find enclosed documentation of tuberculous meningitis, examination of cerebrospinal fluid, hydrocephalus and microbiological data on the infecting organism. Every effort has been made to be as clear as possible regarding the issues in your case. This review and report have been limited to the documents and information you have provided. Should you need further clarification relating to the content of this report, please feel free to contact Associate Director, Kevin S. Billings, or me. It is our policy not to discuss the content of these reports with the plaintiffs involved. This report is not intended for discovery, as it is a confidential Work Product Report prepared at your request. Kevin Billings and I are not available to serve as expert witnesses in this case. We have thousands of Board-Certified medical experts on our consulting staff who can review the records and will testify in support of their own opinions. Thank you for allowing us to assist you by reviewing this interesting case. Sincerely yours, ______________________ H. Barry Jacobs, M.D. Medical Director ______________________ Kevin S. Billings Associate Director HBJ/pbm Enclosure