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CPC

CPC. 6/3/2016. DK – 61 yo F. seizures Idiopathic iridocyclitis and uveitis on immunosuppression T2DM, HTN, HLD COPD, OSA Bedbound for one year due to morbid obesity and deconditioning No pertinent family or social history. History.

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CPC

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  1. CPC 6/3/2016

  2. DK – 61 yo F • seizures • Idiopathic iridocyclitis and uveitis on immunosuppression • T2DM, HTN, HLD • COPD, OSA • Bedbound for one year due to morbid obesity and deconditioning • No pertinent family or social history

  3. History The patient was seen at the VA in 2011 for an event of dysarthria lasting for 24+ hours. MRI was unremarkable, so the event was attributed to a non-epileptic spell given her report of stress related to an abusive relationship. No EEG was obtained during that admission.

  4. History In Nov 2014 she was evaluated following a generalized convulsive event and myoclonus. She reported a h/o seizures in childhood treated with phenobarbital for many years. Her last reported GTC seizure was in 1988. In addition to the GTCs, she reported a history of “drop attacks” and “black outs” in the past, but these were too remote for her daughter to provide further description. She had not been on anticonvulsants for 10+ years prior to the breakthrough seizure.

  5. History EEG 11/2011 notable for generalized poly-spike and wave discharges with an after-going slow wave, maximal over the left frontal head region. No clinical changes were noted with the discharges. The background was diffusely slow. She was started on a slow up-titration of Lamictal at that time, however, developed a rash and this medication was discontinued. She represented to the hospital a couple of weeks later with multiple events, and was started on Keppra 500mg/1000mg. She did not have follow up with neurology until this current admission.

  6. MRI Brain 11/5/2014

  7. MRI Brain 11/5/2014

  8. MRI Brain 11/5/2014

  9. History of Present Illness • 5 months prior to death: new headache, thought to be from Cellcept, so was switched to Imuran 2 weeks prior to death • 4 days prior to death: • awoke with slurred speech, progressed to altered level of consciousness, would open eyes to voice, not follow commands • At VA, initially afebrile, BP 222/106 and HR 93 • had episode of left gaze deviation and lip smacking, followed by multiple episodes of generalized tonic/clonic activity; started on keppra and phenytoin during this time • Became hypoxic, hypercarbic, and hypotensive; daughter was called, code status was reversed from DNR/DNI and patient was intubated • CT head and CTA obtained, unrevealing • Started then vancomycin, bactrim, aztreonam, acyclovir for empiric meningioencephalitis in the setting of penicillin allergy (anaphylaxis)

  10. 3 days prior to death • Transferred to PUH, where had Tmax 38.5, normotensive, hypoxic • completely unresponsive to pain, pupils fixed • wbc 23 • CSF wbc 337 (248 corrected), rbc 71280, gluc 226, prot 217, HSV and VZV negative, crypto negative • EEG: R temporal LPD’s and subclinical R hemispheric seizures • Started on versed • Abx switched to meropenem, acyclovir

  11. 2 days prior to death • Continued to have frequent seizures despite maximizing keppra, phenytoin, increasing versed, and loading vimpat • Increased vent requirements, never stable enough for CT scan or MRI

  12. 1 day prior to death • Given worsening clinical status, daughter opted for CMO given previous DNR/DNI order • Terminally extubated • Family requested brain only autopsy

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