Paula was diagnosed with Acute Lymphocytic Leukemia about three and a half years ago. She had an allogenic stem-cell transplant and was declared leukemia free for three years. However, around two and a half weeks ago her leukemia returned in her cells, as opposed to her donor. She began chemotherapy around two weeks ago. The first six days of chemotherapy she did at Rex Hospital, after which she was sent home. The day before she came home she was feeling very tired, a feeling that increased daily over the next five days. On the fourth day she had a blood culture that came back negative for infection. That same day she began confusing words, asking for things that did not make sense (such as scissors instead of orange juice), and requiring assistance into bed. Also, while trying to lift a 2 lb. weight for exercise she would lift it once perfectly, become unable to lift it, and then lift it once again. By sixth day she had to be taken to the hospital because she had no mobility, where she was admitted into intensive care with an extremely low blood pressure (the arteries in her arms had contracted to let more blood flow to her brain and heart) and dehydration. They tested her for liver function and it was working fine. She quickly degraded in speech ability and mental functioning and by the end of the night was in a coma with profound septic shock. She had a 102 degree fever, an average respiration rate of 50 breaths per minute, a WBC of 100/mm³, and a heart rate around 150 beats per minute. They gave her around four liters of fluids, steroids, and antibiotics, then realized that the treatments had caused a lot of fluid to third space in her lungs. This, along with the stress of the situation, increased her respiration rate to around 50 breaths per minute, so she was put on a respirator at 100% oxygen. They also put her on Vasopressin to increase her blood pressure. The next day, she was unresponsive to everything except pain stimuli. Her blood pressure would drop drastically whenever the Vasopressin drip was changed out and she was still receiving high levels of oxygen. The third day in the hospital, she was steadily weaned off of the Vasopressin and reduced to 30% oxygen. At this point she had received no food in the hospital and no more than a few bites of food for the two days prior to her admittance. The fourth day she had a WBC of 200/mm³, a slight fever, and blood pressure around 155/90, which is moderately high for her but of no immediate concern. The fifth day, however, her blood pressure, at times was as high as 185/110, which concerned the doctors enough to give her a blood pressure reducer. At the same time her breathing sped to around 35 breaths per minute, and her blood oxygen level dropped to a low of 90 but averaged around 95. On the positive side, her fever was temporarily gone and her WBC was 400/mm³. Unfortunately, the fifth day also brought a complication, in that Paula’s bilirubin level was up to 12 mg/dL. Her oncologist decided that she should undergo a percutaneous fluoroscopic colisistotomy. By nighttime of the fifth day her bilirubin level was 15 mg/dL and her fever had returned to a rectum measure of 102 degrees, but her WBC had doubled to 800/mm³. Her sixth day in the hospital Paula open her eyes without any stimulation and held them open for about thirty minutes, closing them only for brief moments, after which she would be asked to open her eyes and she would. That night, however, she was, again, virtually unresponsive. From then on, when she would respond to stimuli by opening her eyes, her eyes would stay open longer than previously. They would stay open for anywhere from a few seconds to five minutes, but she did not seem to be focusing. Her bilirubin level also jumped to 17 mg/dL but her protime was at 1.2. Although her WBC continued to rise, to 2100/mm³ and her neutrophils were at 1600/mm³, her platelets continued to drop to around 8000/mm³. For some reason the weekend doctors decided not to do the colisistotomy, and suggested a sit and wait approach instead. The seventh day in the hospital, Paula’s condition continued to worsen. Her bilirubin rose to 18 mg/dL and her gallbladder remained swollen. However her platelets had risen to 18. The next day, day eight, she had two ultrasounds and an EEG. The ultra sounds did not reveal a blockage but they did show that her gallbladder was full of sludge. One doctor used the analogy that while a normal person may have gallstones, Paula has gravel. A GI specialist also saw her and adamantly recommended that the colisistotomy be done the next day. The EEG revealed that her brains condition had not changed and was still operating at around 1 Hz, whereas a normal person would be around 10-12 Hz. When her primary physician, Dr. Crane, came back on day nine, he said that he had been in contact with the other doctors and that they were going to go ahead with the operation no matter what; even with her platelets staring at 8. He said that they would try to get the platelets up to 50, but even if they could not, it would still be a go. He also said that this was her only chance; that if she does not turn around through this procedure then it could be days before she goes and there is nothing that can be done about it. He also said that her blood sugar and salts are very high, due to the fact that as a normal person may have a gallon of fluids to dilute a cup of salts, Paula only has a cup. On day eight her blood sugar was at 224. Paula has never had any previous GI issues, other than a period where her liver enzymes spiked about eight months ago, presumably due to GVHD. The titles that have been given to her condition are acalculus cholecystitis and encephalopathy.Reply Follow This Thread Stop Following This Thread Flag this Discussion
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