Laboratory Values on Admission: BUN 13, creatinine 1.3, sugar 98, amylase 46, cholesterol 116, electrolytes normal, calcium, magnesium and phosphate normel, alkaline phosphatase 50, total protein 8.5, albumin 4.1, total bilirubin 0.1, SGPT, SGOT and LDH all normal, uric acid 5.8. While being treated with cytosine arabinoside the SGPT and SGOT rose out of the normal range and in the one week prior to death he had bilirubin elevations to as high as 6 as well. There was never any evidence of disseminated intravascular coagulation on twice weekly coagulation screening tests. Problem No, 2 - Thyroid Status: Clinically, the patient was euthyroid. Thyroxine level was 3.7. hospital stay he was continued on L-thyroxine, 0.3 mg. daily. Throughout his Problem No. 5 - Otitis Media: The patient was treated with oxecillin and gentamicin followed by ampicillin for a total of seven days with resolution of his left otitis. Problem No. 6 - Periodontitis: The dental consultant recommended managing his molar periodontitis with frequent local lavage, which was done under his supervision. The initial inflammation resolved - after several days, but during the last three weeks of his hospitalization he had severe peridontal inflammation, worse on the right. In addition, a right subauriculear swelling appeared late in the second hospital week and persisted until the time of death, Ear, nose and throat consultant thought this represented parotitis, but reactive adenopathy from the periodontitis could not be excluded. During the last three weeks of hospitalization ‘ne was on nearly continual antibiotic treatment with oxacillin and gentamicin or keflin and gentamicin. On November 8 Proteus mirabilis and Pasteurella mlticida were cultured from the blood. These organisms had previously been cyltured from the mouth as well, and a likely source of sepsis was his periodontitis. He continued to be febrile throughout the rest of the hospital course, but subsequent blood cultures were sterile. Problem No. 7 - Pneumonitis: On November 7 the patient had gram-negative sepsis; on November 8 he complained of a brassy cough; on November 9 he was generally tachypneic and quite anxious, with cyanotic nail beds. Physical examination revealed right axillary rales and chest x-ray showed a patchy alveolar infiltrate in the right upper, middle and lower lobes. Arterial oxygen saturation was 45 om. of mercury on room air and pCO, and 20 mm. of mercury. Cultures of the scanty blood-tinged sputum grew only a few colonies of Klebsiella. Over the next two days he had increasingly severe respiratory distress with gradual opacification of both hemithoracea on chest x-ray. His sputum became frankly bloody. On November 12 he was intubated by the on a volume cycled respirator. nasotracheal route and placed He was begun on treatment empirically with pyrimethamine and sulfadiazine for the possibility of Pneumocystis carinii pneumonitis. Management CUNICAL a&CoRD Rongelap (54) 09-44-40 3 OC Mery end Physiesi Exemantion -~ §THE CLINICAL CENTER NATIONAL INSTITUTES Of HEALTH - 144 - SA somery C1 Conasitation C1 tetewup 0 Cominvetion Narrative NIK-OFF (Mev. 5-71)