Category Archives: ILLNESS

ME IN 2014

7th December 2015

Dr Kelly Hamill

North Bellingen Medical Centre

58 Wheatley Street

Bellingen NSW 2454

Dear Dr Hamill,

RE: LYNNE SANDERS-BRAITHWAITE

MRN: 130 02 61

DOB: 19/10/1949

BACKGROUND:

  1. Chronic liver disease secondary to chronic hepatitis C (CHC) and previous excessive alcohol consumption.  Child Pugh score A5, previous episode of decreased level of consciousness and peripheral oedema, chronic hypoalbuminaemia 26 g/L, mild elevation bilirubin 22 umol/L.  INR 1.4, platelets 48 x 109/L (chronic suppression), normal bone marrow biopsy previously.  Dr John Gibson, RPAH.  Ongoing moderate hepatitis ALT 56 U/L.

1.1            Chronic hepatitis C (CHC) genotype 1A, viral load 5.6 log IU/mL likely contracted through intravenous drug use in 1972, treated in 1997, no ongoing injecting drug use or Opioid substitution therapy.

1.2            Previous excessive alcohol use until 9/1997 now resolved.  No ongoing alcohol use.

1.3            Hepatitis B core antibody positive, hepatitis B surface antigen negative.  Hepatitis B surface antibody 54 IU/ml consistent with previous exposure with ongoing immunocompetency.

1.4            Hepatocellular carcinoma screening, November 2015; cirrhotic liver with splenomegaly, no liver lesions., organs otherwise unremarkable.  November 2015 alpha-fetoprotein 13 ug/L.

1.5            No previous bone mineral density.

1.6            No previous dietician reviewed albumin 26 g/L for nocturnal protein supplementation.

  1. Previous cardiomegaly with no specific diagnosis.  Echocardiography November 2015 normal LV size and systolic function, mild to moderate dilatation of left atrium, mild pulmonary hypertension, ejection fraction 64%.
  2. Morbid obesity.  Weight 100 kg.  Height 152 cm.  BMI is 42.8.  No previous dietetic intervention.

MEDICATIONS: Frusemide 20 mg daily, Spironolactone 50 mg daily and Salbutamol prn ALLERGIES: No known.

Thank you for referring Lynne to clinic regarding her chronic liver disease secondary to chronic hepatitis C (CHC) and resolved alcohol excess. She is a 66-year-old woman living independently in Urunga with significant history of bereavement and health crisis during 2014, which nearly resulted in death.  Since that time she has improved significantly and been able to resume home life independently. She has not previously had specialist liver review.  She is known of CHC for many years and nominates intravenous drug use from 1972 onwards as the likely source of infection.  During the period 1972 through 1987 she consumed alcohol and used intravenous drugs and was able to control substance abuse initially with IV substitution therapy and eventually through Narcotics Anonymous to avoid all ongoing issues with drug and alcohol since that time.  She has not previously had therapy for CHC. 

Lynne’s health issues in 2014 were described as decompensation of her cirrhosis in the setting of severe pneumonia which resulted in loss of consciousness and ICU care for several weeks and involved significant fluid overload. Since that time, her fluid overload has mostly resolved and she has no ongoing features of encephalopathy that previously troubled her.  Her other health issues relate to dyspnoea and morbid obesity; I believe these to be linked.  She is morbidly obese with BMI of 42.8 and has significant difficulty moving with this weight.  She has not undertaken exercise or diet programs and has no previous referral for bariatric surgery. She was previously described as having cardiomyopathy with dilatation of the cardiac changes, however her most recent echo does not demonstrate features of cardiomegaly and has normal left ventricular size and systolic function. Her echo shows mild pulmonary hypertension which may contribute to breathlessness, however I feel that her muscle bulk is likely to be quite modest in her body which is requiring significant exertion and I believe her breathlessness relates to both her liver disease and her obesity rather than cardiac or respiratory function.  She is not previously known to have ischaemic heart disease.

On examination, Lynne is obese with a soft abdomen and no evidence of ascites. She has splenomegaly and otherwise unremarkable abdomen with minimal tenderness. She has very mild peripheral oedema and few other stigmata of chronic liver disease. Her respiratory examination is unremarkable without crepitation at the bases. She had dual heart sounds which were faint. She had no signs of encephalopathy. Blood testing from November 2015 shows moderate elevation in ALT 56 U/L with other enzymes elevated, deranged liver synthetic function with albumin 25 g/L, bilirubin 22 umol/L, INR 1.4. She had profound thrombocytopenia 39 x 109/L with normal haemoglobin and normal iron studies. She has recent testing for HCV infection with genotype IA, viral load 5.6 log IU/mL and evidence of previous exposure to chronic hepatitis B with HBc antibody positive in the absence of other markers of ongoing infection. Ultrasound of the abdomen performed in November 2015 shows a cirrhotic liver with no evidence of hepatic lesions, splenomegaly and no note of ascites present. Her alpha-fetoprotein was marginally elevated consistent with her level of elevation in ALT. She has not previously had gastroscopy and has never had upper GI haemorrhage.

Lynne is reluctant to have antiviral therapy for her CHC and is unsure where she would like to be treated should this became available. The standard of care in 2016 for genotype IA infection would be three months of oral antiviral therapy using either Viekira Pak or Harvoni both of which are due to became available through the PBS over the coming months.  Liverpool Hospital treatment team consist mainly of nursing and medical staff with significant experience that are dealing with advanced liver disease and this would be an appropriate environment for Lynne.  This is a long way from home and presents significant logistics complications.  I am happy to work with local services in Coffs Harbour or in the Bega area where her son lives should treating physician be available.  In the meantime, I have asked her to alter her diet to involve high protein supplementation nocturnally (for instance, Sustagen in milk prior to sleep), a low salt diet low in other carbohydrates to try to reduce her weight.  I will seek advice on diet solution for Lynne by involving the dietician from the Royal Prince Alfred Liver Unit who has specific skills in this area. Certainly, salt free diet will benefit her with respect to fluid overload and to this end I have introduced Spironolactone 50 mg daily to assist in loss of fluid.  I would recommend water based exercise such as walking around the shallow swimming pool to assist with weight loss. I think that prophylactic banding of varices should they be present would be ideal.  However organising gastroscopy may be complex and I have not addressed this as yet. Lynne needs bone mineral density study and should have vitamin D supplementation with or without osteoporosis care if indicated. I frequently use Zoledronic acid annually and for osteoporosis care. I think that Lynne has intermediate prognosis from her cirrhosis and may benefit from control of her viral infection, however with the current profile of obesity she may struggle to overcome her significant health issues. She requires ultrasound of the abdomen every six months to assess for new lesions related to hepatocellular carcinoma and six monthly alpha-fetoprotein as a standard of care. I will be happy to see her on ongoing basis and/or provide support to treating physician who may review her regularly.

Yours sincerely,

Dr Scott Davison

Staff Specialist, Gastroenterology and Hepatology

Liverpool Hospital

cc              Clinical Information, Liverpool Hospital

cc              Gastro file

SEPSIS ON MY MIND

BY ZOE C. 

Another hand full of pills
Another time I’ve lost all will
Another yelp as I move
Another promise times will improve

Another scare as I lose my sight
Another battle to try and fight
Another series of painful tests
Another long well needed rest

Another day
Another deep breath
Another reminder of the love surrounding me
Another loving message from my family
Another blessing in disguise
Another friendship found for life
Another…..

DOCTOR. HOME AND KIDS.

The Doctor is a sweetheart. However, it was as I expected. He listened looked at me and told me to come back in 2 weeks.

I shed a tear. Something I rarely do.

I told him I have PSS but he had never heard of it. 

So I came home. Well, first I met Kaybee at Grams. Se is living in the same horror movie as me. But she is older, deaf and hasn’t lived alone like me. 

Then I came home and had hoped to go to Aldi with the Girls but I am still far too weak. 

Some things are beyond words because the words do no good.

I have 2 fans now from Kaybee and the flat is sweet and cool. 

Now miserable though I am at the moment and fully worn out, I am also lucky enough to have sustained a few ways of thinking and feeling for a year or more that keep me doing dandy.

One is ACCEPTANCE in a way I did not expect. And an awareness that it has actually been a damned fine life that I have led.

A freedom from feeling that I should, could or need to – fix anything for anyone. 

A peace of a strange kind is usually with me. A kindness to my Self. An affection for people.

Most of the time I am free of Fear and Discouragement. Didn’t expect that.

ROSIE’S DAY

A lovely rather hot day. Still so weak that I can barely move. It was Rosie’s day and I spent most of the morning and afternoon asleep on the bed I now have on the verandah. Rosie cleaned my flat and then went shopping for me. I have some tidbits of good taste now. I thought it was Miss 5’s orientation for Kindergarten and I waited for a phone call but none came. I called after school and spoke to Miss 8. Orientation is tomorrow. She said that they had a good Halloween. Later in the day I heard a brushcutter real close and it was indeed in my yard. The young man from next door was doing the dead branches of the bananas and other feral plant life. It looks good now. He trimmed and trimmed. Deb will be glad because the snake may find it more difficult to get on to her verandah. Once you have seen someone die in an instant like Izzy, nothing is really the same again. I am still struggling across the desert and swamps and fierce oceans on the other side of that. Today – the roses are pink and smell sweet. Tonight – the world is quiet and bed is nearby. I am off the walker and mostly off the stick but a little shakey on balance.The fluid is easing. I have some strange hive like things and some blood spots. I am too weak to do much but I was able to shower. Good Night World. I do like living in you.

QUIETLY

I dont know whats going on. I am better today than yesterday but not well. I am happier with a mown yard. The Girls brought me home cooked food and an orange and we laughed a little. 

I want to do halloween tomorrow but may not be able to. How does one keep going on like this ? 

I call it the year of my dying. I may well live 20-30 more years or I may not live another year – but a surrender into dying is on me. Each time I come down with infections and body failure and a curious disinterest in many things.  Each time I am unable to do another thing – like walk to the top of my path – or walk along the verandah , something dies a little. Not even miserably – just in acceptance.

I have been home now for a week or more and only just walking a little freely today. My flat is at the back of a residence and is surrounded by hedges. So – pretty much for a week – there is just me most of the time. Sometimes birds and helpers. But mostly me alone. And mostly deeply content. Sometimes in pain and hurting. Sometimes a little restless and lonesome. 

Sometimes my thinking and re-membering wander all over the place. Into the many strange sleep patterns of the last 4 years. Of the hospital stays and sudden emergencies. Of the thinking I was making progress and then failing to hold that progress. 

Sometimes I yearn for things. Like going to the Eden Whales Festival and doing halloween and the Fete on Saturday. 

But I seem to have been released from clinging to much – even thoughts or emotions. Or desires. I think to myself – I would like to live somewhere else. But its a mild thought and I am happy here.

I think to myself – I wish such and such an event had gone differently – but then I think – no I don’t.

I wonder whether I would sleep if I went to bed now. Things are very much better for me now as regards my beds. They are comfortable. They work. The whole room works. 

I have the wheelie walker which I keep beside the bed with my phone and iPad and other oddments in. Then when I go to the loo in the middle of the night I have a buffer and support. 

I always thought I would be alone like this as I have been for so much of my life. But after the years with Izzy I began to think that it was a load I would not have to carry alone Then he was gone and aloneness was back but so much more difficult with the degree of illness. And the occasional DAMN I give is mostly over that. I thought I had a helpmeet and companion and lover. But I dont. So I live as I am living now. Into the Dying.

Each time that my Outer World shrinks – I simply adjust but some days it unnerves me.

Now for Bed and Book. My iPhone actually which is turning out to be my favourite. 

THE LIVING YOUNG BREATHE LIFE SPIRIT INTO ME

TIRED AND SORE

Another crippled up day.. Another day of medicines. Swollen feet and legs. 

Flucloxacillin.

My body feels like it has been beaten all over and my head is now blancmange. Jeesh I have only been out once this week. Friday to the Doctor.

Potassium.

And confusion. I dont know what to do. I certainly wont be writing anything inspirational for you. I just sit here and wait for the pain tp pass, Sit here and wait to walk again.

I just SIT. And when I am weary enough I get into bed which is itself difficult  and hope that sleep will come gently. I seek deeper meaning but find none. I am quite happy except when I try to move. My  Eden peoplesaw echidna yesterday and the necklace Dean Beale made for me has echidna quills and kangaroo bone. Seems to me that I pass through a day and see, hear and learn things. And then I smile. Much of the tortuous thinking has gone these days. There is no use kicking at the Goads.Staying in one place has reduced struggle very much. Having Aged Care in place has done the same thing.

So bed comes soon and a book. Well I read on my iPhone which I am enjoying. Bed and warmth and sleep. 

Common antibiotic doctors say could give you organ failure | Daily Mail Online

New guidance, published this month, argues for severe restriction of the drugs – and for both patients and healthcare professionals to be made aware of ‘the disabling and potentially long-lasting side effects’.The drugs in question are fluoroquinolones and quinolone antibiotics. They work by targeting an enzyme in the cell of a bacteria which stop it replicating its DNA. By not being able to carry out this process, the bacteria are destroyed.These antibiotics are very effective, but are able to penetrate tissues throughout the body, including those in the nervous and musculoskeletal system. This can cause damage to normal tissues and result in many complications.

Source: Common antibiotic doctors say could give you organ failure | Daily Mail Online

Observations From ICU Patients We Thought Were Asleep, but Were Not | Critical Care Medicine | JN Learning | JAMA Network

What if the patient you are managing in the ICU is not asleep when you thought they were? Patients relate their very disturbing stories about what they experienced while in an ICU and their treating clinicians thought they were asleep.

Source: Observations From ICU Patients We Thought Were Asleep, but Were Not | Critical Care Medicine | JN Learning | JAMA Network

Symptoms – Sepsis Alliance

It’s important to look for a combination of the warning signs of sepsis. Spotting these symptoms early could prevent the body from entering septic shock, and could save a life.T – Temperature higher or lower.Your body’s temperature should stay fairly constant, around 98.6 degrees Fahrenheit (37 degrees Celsius), moving up or down a bit depending on your activity, the environment, and time of day. A temperature of 100 degrees Fahrenheit (37.7 degrees Celsius) is considered to be hyperthermia, a fever. When you have an infection, your body’s temperature usually rises as it tries to fight off the bug causing the infection. Interestingly, some people see their body temperature go down (hypothermia) instead of up. This is why any change, high or low, can be a sign of sepsis.I – Infection – may have signs and symptoms of an infection.If you have a local infection, like a urinary tract infection, pneumonia, or an infected cut, the signs and symptoms are localized according to the area affected (needing to urinate or burning on urination for a UTI, coughing and chest pain for pneumonia, redness and pus for an infected cut, for example). If the infection has spread or you have a generalized infection, you may develop other signs and symptoms, such as fever, fatigue, pain, etc.Sometimes however, you may have an infection and not know it, and not have any symptoms. Keep this in mind especially if you have recently had surgery or an invasive medical procedure, a break in your skin, or you have been exposed to someone who is ill.M – Mental decline – confused, sleepy, difficult to rouse.Sepsis can affect your mental status. Some people, especially the very old, may not show typical signs of infection but they may show a sudden change in mental status, becoming confused, or a worsening of dementia and confusion. Sleepiness, often severe, is a common complaint.E – Extremely ill – “I feel like I might die,” severe pain or discomfort.Many sepsis survivors have said that when they were ill, it was the worst they ever felt. It was the worst sore throat, worst abdominal pain, or they felt that they were going to die.

Source: Symptoms – Sepsis Alliance

Low potassium (hypokalemia) Causes – Mayo Clinic

Low potassium (hypokalemia) has many causes. The most common cause is excessive potassium loss in urine due to prescription medications that increase urination. Also known as water pills or diuretics, these types of medications are often prescribed for people who have high blood pressure or heart disease.Vomiting, diarrhea or both also can result in excessive potassium loss from the digestive tract. Occasionally, low potassium is caused by not getting enough potassium in your diet.Causes of potassium loss include:Alcohol use (excessive)Chronic kidney diseaseDiabetic ketoacidosisDiarrheaDiuretics (water retention relievers)Excessive laxative useExcessive sweatingFolic acid deficiencyPrimary aldosteronismSome antibiotic useVomiting

Source: Low potassium (hypokalemia) Causes – Mayo Clinic