Day +19, Thursday, April 21, 2016

WBC: 1.43 k/uL LOW  H: 8.5 g/dL LOW  P: 18 k/uL LOW  BUN:  83 HIGH  Cr: 4.3 CRITICAL  Na+: 150 HIGH

Mentation.  Dad was alert when Dr. Ochoa-Bayona, inservice BMT, visited.  He oriented to person, place, and time, but he closed his eyes during conversations.  Dad was mildly confused when Dr. Baluch, BMT infectious disease, visited.

Blood.  Repeated testing for BK virus.  Got D5 water IV.

Mouth and Throat.  Dad requested ice chips, but was still not permitted due to aspiration risk.

Lungs.  Dad continued to breathe on his own.  He continued to cough and have thick secretions from the mucositis.

Abdomen.  Diarrhea continued.  Dad’s feeding was still suspended due to the diarrhea.

Kidneys.  Urine output improved again.  Saw a slight increase in creatine (Cr).  Monitored sodium (Na+).  Urine culture conducted.

Day +20, Friday, April 22, 2016

WBC: 2.34 k/uL LOW  H: 8.2 g/dL LOW  P: 14 k/uL LOW  BUN:  85 HIGH  Cr: 4.8 CRITICAL  Na+: 148 HIGH

Mentation.  When Dr. Ochoa-Bayona, inservice BMT, visited in the morning, he found Dad to be more confused than the previous day.  Dad could only orient to a person.  Dad didn’t know where he was nor the date.  He was slurring his speech.  Dad remained in a confused state when Dr. Chemaly, nephrology, visited midday.  Dad would only repeat back what Dr. Chemaly said.  When Dr. Baluch, BMT infectious disease, came by in the evening, she felt that Dad had worsened confusion.

An EEG was performed, which tested Dad’s cerebral function.  The result was abnormal and initially suggested nonspecific moderate to severe brain malfunction.  No seizure activity was observed during the study.  Dad’s case was reevaluated and noted that Dad had experienced acute renal (kidney) failure, BUN level was high at 85, and creatine (Cr) was trending down.

A CT scan of Dad’s brain indicated no acute cerebral lesions but did show that Dad’s sinuses were irritated and inflamed.

An MRI of Dad’s brain showed no acute changes.  The MRI ruled out stroke and abscess.

Dad’s mental state to be pursued as caused by infection, toxins or metabolic problems.  Dr. Chemaly believed that Dad’s mental state was unlikely due to uremia, a condition involving abnormally high levels of waste products in Dad’s blood.

Dr. Ochoa-Bayona withheld narcotics and sedatives.

Blood.  Increased D5 water IV.

Mouth and Throat.  Based upon the result of the CT scan of Dad’s brain, ENT (ear, nose & throat) was consulted to check for fungal sinusitis.  ENT performed a bedside Flexible Nasal Endoscopy, which showed no evidence of a fungal infection.  It did show a clear, runny nose.  ENT recommended continued IV antibiotics for viral and bacterial sinusitis.

Lungs.  Dad was placed back on supplemental oxygen at 2L.  He continued to cough and have thick secretions from the mucositis.

Abdomen.  Dad’s feeding was still suspended.

Kidney.  Dad’s urine output continued to improve and no longer contained blood.  Dr. Chemaly, nephrology, wanted to avoid dialysis given the possibility of an ischemic stroke, which occurs as a result of an obstruction within a blood vessel supplying blood to the brain.