Have any medical knowledge? PLEASE help if you can.

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2012-05-17 11:28 AM

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Melon Presser
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Subject: Have any medical knowledge? PLEASE help if you can.

I apologize--I am asking for free medical advice. Unfortunately the medical care here in Indonesia isn't very good, and I desperately need your wisdom because I am essentially making all the medical and care decisions for my mom right now. I live on another island but will be flying tomorrow to see her myself.

Please let me know any thoughts (even just brief phrases or keywords are welcome) or questions you have, anything I should further research (I am fairly fluent in medicalese and sciencese, so to speak), any questions I should ask her physicians, any tests I may want to think about ordering or have done, any conditions I should be considering.
Thank you so much for your time.

My mom is 78, walks 3 or more miles every morning and is active around the house. She has moderately progressed Alzheimer's, and for atrial flutter has been (successfully) treated with a low dose of amiodarone (I wish there had been other options, but there aren't here) and fairly standard dosages of warfarin (blood thinner) since last December. She is otherwise in excellent health.
Yesterday on her walk she collapsed, was taken to ER. She had a fever of 104F and was having what the first ER doc believed to be complex febrile seizures in her legs. Reflexes good and responsive to pain, but not otherwise responsive (including to familiar people). Agitated and kept moaning "ah, ah." Slightly elevated pulse and BP, EKG normal, respiration slightly increased but perfusion good.

Head and chest CAT scans (no contrast) showed what appeared to be diffuse pneumonitis but otherwise normal. Part of her CBC is attached (all values not shown were in normal range). Dengue and typhoid tests returned negative (but they do not usually register positive until several days after onset of fever). Initial urine and stool samples normal; both stool and blood are being cultured. She was given IV Valium, paracetamol, moxifloxacin (Avelox, which is to be taken with caution with amiodarone, but to be fair, just about everything, including valium as well, is). Valium did not initially decrease agitation or leg spasms (occuring roughly every 3-5 minutes until now). After several hours she was started on Haldol (which is also somewhat contraindicated with amiodarone) to try to control the leg spasms and agitation (and continued on reduced dosage of valium, still). Haldol is generally not used in elderly persons with dementia because of increased risk of death. It was discontinued at my request after two administrations.

Fever reduced to normal but spiked again to 102F  afternoon of following day, is receding now late at night again (btw, typical of typhoid). Today she has been less agitated, and more responsive, can follow simple commands in German (squeeze my hand, look here), seems to recognize family and sometimes communicates in simple, short slurred sentences of German (her native tongue). Vital signs are stable, some elevated along with fever, but otherwise normal.

My gut feeling at this point is that this is typhoid fever, possibly dengue (possibly both). My sister recently after returning from a trip to my parents' fell ill with dengue + typhoid. Another possibility or complication is amiodarone-induced pulmonary toxicity.

I will post more tomorrow when I can examine her myself and look at her charts, exact treatment and results. My brother and father feel she's stable and receiving adequate care at the moment, but med-evac'ing her to Singapore is an option.
Thank you again so much for your time and consideration.





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2012-05-17 11:35 AM
in reply to: #4215024

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Master
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Washington, DC Metro
Subject: RE: Have any medical knowledge? PLEASE help if you can.
I can offer no assistance whatsoever, but I will keep you and your mom in my thoughts and prayers this weekend.  I wish you both the best.
2012-05-17 11:50 AM
in reply to: #4215042

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Melon Presser
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Subject: RE: Have any medical knowledge? PLEASE help if you can.

Sous - 2012-05-18 12:35 AM I can offer no assistance whatsoever, but I will keep you and your mom in my thoughts and prayers this weekend.  I wish you both the best.

Deeply appreciated. My personal belief is that prayer is excellent medicine, and in any case, you've cheered me up.

2012-05-17 11:57 AM
in reply to: #4215024

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Coach
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Subject: RE: Have any medical knowledge? PLEASE help if you can.
Wow, I hope she continues to stabilize adn improve.

My gut response is that for fever, altered mental status and neuro/psych changes a spinal tap is in order.

I'm not upto speed on my tropical diseases, but dengue is just supportive treatment. I've never heard of a "localized seizure in the legs", although complex focal siezures can occur but are typicall unilateral, because they are focal in the brain...it would be incredibly odd to have symmetric focal activty that doesn't involve the entire cortex, or spread in a typical wave fashion.

That being said, the treatment may be valium/ativan for muscle spasms not other wise defined. The pneumonitis finding might be conincidental, but i've treated a zillion people who take amiodorone on a long term basis and only seen 1 case that I know of of amiodorone toxicity...and that was as a med student in the ICU...long time ago.

Be well, and fee free to PM with other questions.
2012-05-17 12:01 PM
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Melon Presser
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Subject: RE: Have any medical knowledge? PLEASE help if you can.

AdventureBear - 2012-05-18 12:57 AM Wow, I hope she continues to stabilize adn improve. My gut response is that for fever, altered mental status and neuro/psych changes a spinal tap is in order. I'm not upto speed on my tropical diseases, but dengue is just supportive treatment. I've never heard of a "localized seizure in the legs", although complex focal siezures can occur but are typicall unilateral, because they are focal in the brain...it would be incredibly odd to have symmetric focal activty that doesn't involve the entire cortex, or spread in a typical wave fashion. That being said, the treatment may be valium/ativan for muscle spasms not other wise defined. The pneumonitis finding might be conincidental, but i've treated a zillion people who take amiodorone on a long term basis and only seen 1 case that I know of of amiodorone toxicity...and that was as a med student in the ICU...long time ago. Be well, and fee free to PM with other questions.

THANK YOU. You are an angel. Swimming, and otherwise. I will be with her and having a chat with her doctors within 12 hours, so I will definitely keep the spinal tap in mind.

2012-05-17 12:07 PM
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Subject: RE: Have any medical knowledge? PLEASE help if you can.
No medical knowledge, but lots of hugs and positive vibes!

2012-05-17 12:09 PM
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Melon Presser
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Subject: RE: Have any medical knowledge? PLEASE help if you can.

ratherbeswimming - 2012-05-18 1:07 AM No medical knowledge, but lots of hugs and positive vibes!

{MELON PRESS} back atcha.

2012-05-17 12:11 PM
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Payson, AZ
Subject: RE: Have any medical knowledge? PLEASE help if you can.
No medical advise here either but I will be keeping your mom in my thoughts.  And you miss, you take care of yourself while you are there taking care of your mom.  You will do no one any good passed out sicker then everyone else. 
2012-05-17 12:33 PM
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Pro
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Subject: RE: Have any medical knowledge? PLEASE help if you can.

Likewise, I don't have any medical advice, but I'm sending you and your Mutti heaps of love and positive mojo.  She is obviously a strong woman to be walking 3+ miles every day!  I hope you get to the bottom of whatever it is that's affecting her, and that she recovers quickly and fully!

2012-05-17 1:32 PM
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Subject: RE: Have any medical knowledge? PLEASE help if you can.
Yanti, you are a wonderful advocate for your mother. It's so hard when one can't be "the daughter"and trust the doctors are doing well. Lots to consider. Amio toxicity as Adventure Bear stated is much less likely epecially acutely. Stroke is certainly a possibility with subsequent aspiration which can cause pneumonitis. May not show up on CT head. The elevated blood pressure is often a tip off after a stroke (or TIA) as it is cerebral protective. The brain will raise blood pressure to maintain its own perfusion. I am concerned with the antibiotic choice as it can raise Coumadin levels and there are suitable alternatives if they truly believe she has a bacterial pneumonia. A spinal tap should be done if meningitis is a concern but wonder if the fact she was on Coumadin was their reasoning initially. As she is improving without direct treatment for bacterial meningitis this is less likely although viral is still possible.I would insist they evaluate her swallow.I would also point out to you Yanti that you need to take care of yourself too!! Jim
2012-05-17 1:32 PM
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Subject: RE: Have any medical knowledge? PLEASE help if you can.
Yanti, you are a wonderful advocate for your mother. It's so hard when one can't be "the daughter"and trust the doctors are doing well. Lots to consider. Amio toxicity as Adventure Bear stated is much less likely epecially acutely. Stroke is certainly a possibility with subsequent aspiration which can cause pneumonitis. May not show up on CT head. The elevated blood pressure is often a tip off after a stroke (or TIA) as it is cerebral protective. The brain will raise blood pressure to maintain its own perfusion. I am concerned with the antibiotic choice as it can raise Coumadin levels and there are suitable alternatives if they truly believe she has a bacterial pneumonia. A spinal tap should be done if meningitis is a concern but wonder if the fact she was on Coumadin was their reasoning initially. As she is improving without direct treatment for bacterial meningitis this is less likely although viral is still possible.I would insist they evaluate her swallow.I would also point out to you Yanti that you need to take care of yourself too!! Jim

2012-05-17 1:38 PM
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Master
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Subject: RE: Have any medical knowledge? PLEASE help if you can.

I am not a doctor but I did stay at a Holiday Inn Express last night.....

No knowledge but I will keep you both in my prayers. I hope all will be well. Big Hugs from Bmore, MD!

2012-05-17 1:39 PM
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Champion
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Subject: RE: Have any medical knowledge? PLEASE help if you can.
Her white count is elevated which is an indicator of infection.   not a surprise.  Mkae sure they check her electrolytes because an abnmormality there will make her confused and could account for the leg spasms
2012-05-17 1:47 PM
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Elite
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Subject: RE: Have any medical knowledge? PLEASE help if you can.
wow, honey, with your medical issues and taking on your mother's, my prayers are  with you as well! Stay strong.
2012-05-17 1:50 PM
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Master
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Subject: RE: Have any medical knowledge? PLEASE help if you can.

I am not sure if this is in the range of possibilities.

Lyme disease and associated bacterial infections including, Bartonella and Barbiesia.

These can start out as normal bacterial infections and go into the Cental nervous system causing all of the sympotoms you described. This happend to my wife and then reoccured three years later (last november).

It requires a long term antibiotic treatment (3- 6 months) not the prescribed 28 days from the CDC.

Both of you are in our prayers.

2012-05-17 2:04 PM
in reply to: #4215377

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Melon Presser
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Subject: RE: Have any medical knowledge? PLEASE help if you can.

jimmyb - 2012-05-18 2:32 AM Yanti, you are a wonderful advocate for your mother. It's so hard when one can't be "the daughter"and trust the doctors are doing well. Lots to consider. Amio toxicity as Adventure Bear stated is much less likely epecially acutely. Stroke is certainly a possibility with subsequent aspiration which can cause pneumonitis. May not show up on CT head. The elevated blood pressure is often a tip off after a stroke (or TIA) as it is cerebral protective. The brain will raise blood pressure to maintain its own perfusion. I am concerned with the antibiotic choice as it can raise Coumadin levels and there are suitable alternatives if they truly believe she has a bacterial pneumonia. A spinal tap should be done if meningitis is a concern but wonder if the fact she was on Coumadin was their reasoning initially. As she is improving without direct treatment for bacterial meningitis this is less likely although viral is still possible.I would insist they evaluate her swallow.I would also point out to you Yanti that you need to take care of yourself too!! Jim

Jim ... you are a wonderful practitioner and a super Iron guy. Thank you so much. {MELON PRESS}

And yes ... I will guard myself well.

2012-05-17 2:07 PM
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Melon Presser
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Subject: RE: Have any medical knowledge? PLEASE help if you can.

Socks - 2012-05-18 2:39 AM Her white count is elevated which is an indicator of infection.   not a surprise.  Mkae sure they check her electrolytes because an abnmormality there will make her confused and could account for the leg spasms

Thank you so much Doc Soo. I hope you are having a blast

So far they're keeping tabs on her electrolytes, and she's getting TPN, and normal ranges. I'm not sure what kind of equipment she's hooked up to so not sure HOW they're keeping tabs and I'll check on that too.

2012-05-17 2:27 PM
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Veteran
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Subject: RE: Have any medical knowledge? PLEASE help if you can.

Like others, I have no medical knowledge (and my watching medical tv dramas probably doesn't help either...), but also like others I will keep you both in my thoughts! My first instinct said stroke + typhoid---I hope not for both your sakes! Hang in there and take care of yourself! You're no help to her if you knock yourself back down in the process of helping her.

2012-05-17 2:28 PM
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Melon Presser
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Subject: RE: Have any medical knowledge? PLEASE help if you can.

And Kim, Keith, Amy, Matt, and Verga:

Thank you so kindly for your replies and thoughts. You guys are wonderful and I will take all that strength from you and give it to my mom. And me.

Oh Verga ... Lyme is North American almost exclusively. I am so sorry your wife had to go through all that!

P.S. And you too, Kate! Thank you! I thought of you when a giant very fast but not so long centipede-like thing was crawling across my floor. I like them, but hey, you like geckos.



Edited by TriAya 2012-05-17 2:32 PM
2012-05-17 2:29 PM
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Master
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Subject: RE: Have any medical knowledge? PLEASE help if you can.
Can't help much in the medical department; never went much beyond combat first aid.      You, my dear, are in my thoughts.   By what ever gods or goddesses there be, may they smile upon your mother.
2012-05-17 2:35 PM
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Melon Presser
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Subject: RE: Have any medical knowledge? PLEASE help if you can.

MadMathemagician - 2012-05-18 3:29 AM Can't help much in the medical department; never went much beyond combat first aid.      You, my dear, are in my thoughts.   By what ever gods or goddesses there be, may they smile upon your mother.

Well ... I'll smile at my mother; that'll have to do. Thank you, my mad polymath.

2012-05-17 3:18 PM
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Expert
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Subject: RE: Have any medical knowledge? PLEASE help if you can.
I have no medical advice either, but I have lots of hugs and love for you and your family!  
2012-05-17 3:53 PM
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Melon Presser
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Subject: RE: Have any medical knowledge? PLEASE help if you can.

ecozenmama - 2012-05-18 4:18 AM I have no medical advice either, but I have lots of hugs and love for you and your family!  

Thank you, sweet Ecozany!

2012-05-17 4:05 PM
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Expert
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Subject: RE: Have any medical knowledge? PLEASE help if you can.

Thoughts I had  as I was reading your post and replies:

-initial thought: stroke?  Was this just out of the blue or had she complained of not feeling well of late?

-magnesium and potassium are normal - that's good

-i agree with increased WBC, febrile -> infection - pneumonia...?? my first thoughs for  aspiration/community acquired antibiotics are  possibly ceftriaxone and azithromycin...?

-when I read "localized seizures in legs" i thought: what are those?  i'm not familiar...

-agree with ABear - amiodarone tox is rare

-reasonable no haldol request - use lorazapam for muscle spasms/agitation...?

I'm not familiar with tropical dz or the treatment of such, and again, these are just thoughts I had.  Your post will probably percolate in my brain for a bit and if I come up with anything more, I'll let you know.  Good Luck, Yanti - if you get your strength from you mom, she surely a tough, tough lady.

2012-05-17 4:14 PM
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Melon Presser
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Subject: RE: Have any medical knowledge? PLEASE help if you can.
TriRx - 2012-05-18 5:05 AM

Thoughts I had  as I was reading your post and replies:

-initial thought: stroke?  Was this just out of the blue or had she complained of not feeling well of late?

-magnesium and potassium are normal - that's good

-i agree with increased WBC, febrile -> infection - pneumonia...?? my first thoughs for  aspiration/community acquired antibiotics are  possibly ceftriaxone and azithromycin...?

-when I read "localized seizures in legs" i thought: what are those?  i'm not familiar...

-agree with ABear - amiodarone tox is rare

-reasonable no haldol request - use lorazapam for muscle spasms/agitation...?

I'm not familiar with tropical dz or the treatment of such, and again, these are just thoughts I had.  Your post will probably percolate in my brain for a bit and if I come up with anything more, I'll let you know.  Good Luck, Yanti - if you get your strength from you mom, she surely a tough, tough lady.

Thank you so much, Tracy. You are a gem and I appreciate your time.

My mom is a million times tougher than I am. She grew up in a very poor family during WWII, with six brothers, five of them younger. She has also survived life with my dad for over 50 years and the three children that she had.

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