Laboratory Values on Admission: BUN 13, creatinine 1.3, sugar 98, amylase 46,
cholesterol 116, electrolytes normal, calcium, magnesium and phosphate normal, alkaline
phosphatase 50, total protein 8.5, albumin 4.1, toral 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 oxacillin 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 subauricular 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 che last three weeks of hospitalization he was on nearly continual antibiotic treatment with oxacillin and gentamicin
or keflin and gentamicin. On November § Proteus mirabilis and Pasteurella milticida
were cultured from the blood. These organisms had previously been cyltured from the
mouth as weil, 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.
as ee
Problem No. 7- Pneumonitis:

On November 7 the patient had gram-negative sepsis; on November 3 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 mm. 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 hemithoraces on chest x-ray. His sputum became
frankly bloody. On November 12 he was intubated by the nasotracheal route and placed
on a volume cycled respirator, He was begun on treatment empirically with pyrimethamine
and sulfadiazine for the possibility of Pneumocystis carinii pneumonitis, Management

CLIMICAL RECORD

Rongelap (54) 09-44-40 3

CJ] Mistery end Physianl Examination

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THE CLINICAL CENTER:

NATIONAL INSTITUTES OF HEALTH

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Narrative

Censsisntion

Cl tetewup
C] Continuation

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