The SICU story continues.... from Ero Sennin

Last time, I was telling about our 50plus year old lady with a prosthetic metallic mitral valve who came in breathlessness & later on pulmonary haemorrhage. Check the link: http://doctorsbrunei.blogspot.com/2008/05/interesting-chest-x-ray.html

Her pulmonary haemorrhage settled, whilst on heparin & her ventilation requirements did seem to improve. We did a battery of blood tests on her, autoimmune screen turned out negative, and yes, sputum AFBs and PCR AFB turned out negative too. We even did tumour markers, yes a shot in the dark and debated about the relevance of a high CEA. We did however notice her going into obstructive jaundice.

Eventually, she became stable enough for a CT chest, abdomen & pelvis. We were expecting to find lung metastasis. The only thing that was reported from our radiologist was that she had a dilated common bile duct and some narrowing near the ampulla. (I'm recalling this from memory sorry)

After the CT, she proceeded to have a tracheostomy as she had been intubated all this time and we felt it would improve her chances of being weaned off ventilation.

Our friendly gastroenterologist reviewed the CT film and suggested an ERCP, which unfortunately, she was not fit for. She actually deterioated post tracheostomy (acute lung injury) & required a higher ventilation requirement. I thought she wouldn't make here at that time, but she weathered round.

Surprise

It was time to tell the family what we found & what the options were. When we discussed with her husband regarding the CT Abdomen findings, he asked if the 'stricture' in the billary tract was a result of her previous radiotherapy or chemotherapy ! This completely knocked us off our feet, coz' this was not mentioned before and there was nothing in the medical notes to say that she had cervical carcinoma a few years ago !!

We traced the Obs&Gynae notes, which were completely separate to her normal medical notes, to find the cervical carcinoma with NO mets diagnosed in 2006, this was however treated 'conservatively', to summarise a complicated story, at family request. She did however go to KL for chemotherapy and radiotherapy.
Later on, she had a cervical lymph node biopsy which confirmed metastasis, but it is unclear on whether her or her family were informed about this as they refused follow up from then onwards.

With that in mind, we formed a definitive treatment plan with the family, to continue her on artificial ventilation, but not for aggressive cardiopulmonary resuscitation in the event of cardiac arrest.

She slowly continued to deterioate, and died within 1 week after the discussion.

May she rest in peace.