CASE PROTOCOL

MEDICINE GRAND ROUNDS

St. Luke’s Medical Center- Department of Medicine

Medical Grand Rounds
SLCM Library Lecture Hall Dec 13 2019 10:00 AM

“52 year old male presenting with desaturations”

Patient was diagnosed with Parkinson’s disease (PD) 14 years ago managed with
Levodopa+Carbidopa (unrecalled dose) 1 tab three times daily, Baclofen 10mg/tab three times daily
and Escitalopram 10mg/tab once daily. His ADLs have progressively declined through the years and
is now bedridden, assisted in all ADLs, with best response is grimacing to pain, and is fed via PEG.
Due to his PD, he developed sacral ulcers which began in 2015 and were managed under GS service
with wound care (bioscrub and betadinized packing) and would heal. However, two months prior,
patient was noted to have a non-healing sacral ulcer stage IV with the same wound care and there
was noted progressive increase in size and depth of of wound with foul smelling sero-purulent
discharge. One week prior, culture and sensitivity testing sample was collected from the sacral ulcer
due to draining fibrin like discharge. This is not associated with fever, hypotension or desaturation. He
was due for a follow-up in the OPD the following week but during the interim, patient developed
productive cough with inability to expectorate sputum. This is not associated with fever or tachypnea.
On November 25, 2019, during a follow up visit with GS OPD in the afternoon for wound care and
wound discharge culture results, patient was noted on physical examination to have unstable vital
signs with BP of 90/70 HR 112 RR 28-30 O2 sat 87%. Hence, the patient was brought to the ER and
was eventually admitted.

Review of systems revealed muscle weakness but otherwise unremarkable.

Patient was managed with a case of pneumonia one year ago in another institution and was admitted
for 5 days treated with Co-Amoxiclav. He has a history of PEG insertion x 5 which began in Aug
2016. His last PEG replacement was done on Sept 2019 in which he tolerated well. Patient was then
given Cefuroxime 500 mg twice daily for 7 days. He has a history of UTIs this year (April 2019, treated
as outpatient with Ciproflaxin (unrecalled dose) for 10 days and Sept 2019 treated with cefuroxime
500 mg twice daily for 10 days). He also developed an infection on his PEG on Sept 2019 treated
with Cefuroxime 500mg twice daily for 7 days. No hypertension, diabetes mellitus, bronchial asthma,
thyroid disease, pulmonary tuberculosis, myocardial infarction, or stroke.

Patient is a high school graduate and worked as a vendor before being diagnosed with PD. His
caretakers include his mother and his brother. He is a non smoker and previously a heavy alcoholic
beverage drinker (4-5x a week consuming at least 2-4 bottles of brandy per week) but has stopped
since being diagnosed with PD.

He has a family history of nephrolithiasis (mother) and seizures (brother). No family history of
hypertension, diabetes mellitus, stroke, myocardial infarction, or Parkinson’s disease.

Upon admission, patient was awake, non-verbal, and grimaces to pain. Patient is hyposthenic and
weak looking. BP 87/40 HR (manual) 110 RR 35 Temp 38.5 O2Sat 99% 4 lpm NC. He has no pallor,
no jaundice with atraumatic eyes, no regard, intact corneals, intact dolls and no visual threat. His
pupils are 3 mm SRTL. He has anicteric sclera, pale palpebral conjunctiva. He has no distended neck
veins, no cervical lymphadenopathies, and no palpable supraclavicular lymph nodes. He has dry lips
and oral mucosa. He has coarse crackles, bilateral mid to base, and is tachycardic, with regular
rhythm, and no murmurs. He has a soft, non-tender abdomen, PEG in place, with no erythema and no
purulent discharge. Patient has no edema but with a foul-smelling, grade IV pressure ulcer on the
right hip (exposed femoral head). No active bleeding and no purulent discharge. Patient also has
multiple pressure ulcers on the right malleolar. Patient is GCS 6 (E1V1M4).
 CASE PROTOCOL
MEDICINE GRAND ROUNDS

December 7, 2019

Good afternoon, doctor!

Attached in this letter is our Case Protocol for our Medicine Grand Rounds this December 13,
2019 (Friday) 10-12pm. We look forward to meeting with you and learn from this encounter.

Thank you, doctor!

December IM Junior and Senior Interns