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Case Resolution:

Contact is finally made with TB Clinic Social worker, who confirms his
lack of family and indicates that the Outpatient Psych Clinic has been
looking for him for the last three weeks- he carries an additional
diagnosis of Paranoid Schizophrenia, and has been treated with Depo
Prolixin every three weeks, and has missed two shots........


Pulmonary consultant arrives as the patient slumps over unconscious-
b/p found to be 90 palp, resp 24 and shallow. Large bore Nasal
tracheal intubation is performed, and a large amount of foul smelling
pus is suctioned out of the right lower lobe during emergent fiber
optic bronchoscopy- "sulfur granules" are noted in the pus, and the
Pulmo doc orders high dose Pen G IV stat to cover the Actinomycosis
infection in the abbess, as well as the Pneumococcus lobar pneumonia.

Patient is stabilized on the vent, and transferred to MICU, where
aggressive fluid and electrolyte replacement begins to stabilize his
hypovolemic shock, while doses of Florinef (synthetic Aldosterone) and
Solumedrol  are used to replace the Adrenal hormones lost to the early
Addison's disease (secondary to TB of the adrenals). Syndrome of
Inappropriate Antidiuretic Hormone (from the severe lung infection)
has also contributed to his electrolyte imbalance.

Over the next forty eight hours, the patient starts to improve, but
requires increasing doses of sedation to prevent him from fighting the
vent. He forcibly extubates himself on the third day, but is re
stabilized on a high flow face tent after the Psych consult has a
chance to interview him and order a substantial dose of Prolixin
injectable followed by the patient's routine dose of Depo Prolixin.

He is stable for transfer to the floor after 6 days in MICU, and
shortly there after is found wandering off of the floor, trying to bum
a cigarette.

He is discharged AMA on the eighth hospital day, despite efforts to
get him to admit himself to a long term dual diagnosis center for
further treatment of his schizophrenia and alcoholism.

end of case.

Good points were made about the pneumonia and the lung abbess, but no
one twigged on the mental problems (talking over your shoulder to some
one you couldn't see, refusal of procedures, in appropriate answers to
questions...) and no one addressed the obvious electrolyte imbalances
or hypotension beyond specifying that they would start an IV!

Rusty brown sputa with Gram positive lancet or football shaped
diplocci are pathognomonic for Pneumococcal pneumonia. Lung abscesses
in patients with natural teeth (especially in poor repair) or long
term denture hygiene problems should be treated as anaerobic
aspiration types until proven otherwise. The sinus tracts on the CT of
the Chest involving the cavitary lesion were a good clue here- note
that PCN is still a good drug for Pneumococcus, and the drug of choice
in anaerobic infections.

Marked electrolyte imbalances may be as a result of increased losses
(sweating, diarrhea, medication effects), increased
retention/consumption (high salt diet, abusive water or alcohol
intake, renal failure) or hormonally mediated (Addison's or Cushing's
syndrome, SIADH). Often, they need aggressive treatment, especially
with impending shock.

Hope you enjoyed this one- next incident will involve pediatric
trauma.

ck

Charles S. Krin, DO FAAFP KC5EVN, Member, PGBFH
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"Reckless, Hell! I hit jus' where I was aimin'"
   "Bubba Shot the Jukebox!" Mark Chestnut, 1995