Since no information could be obtained directly from the patient, his wife was closely requestioned about symptoms of thyroid disease, or long-standing diarrhea or other GI problems. The paregoric which the patient had taken on the day of admission was brought into the hospital and checked; it was, indeed, paregoric.
During this period the patient was examined by Dr. Leaf, the chief of medicine, and Dr. Federman, the assistant chief, as well as by a large number of other physicians, in an informal brainstorming session. Every conceivable diagnosis, including mushroom poisoning and cholera, was considered at this time.
The patient's condition remained unchanged.
Continued problems with oxygenating the patient's bloodstream produced a consultation by the respiratory unit, which advised drying the lungs as much as possible, nasotracheal suctioning, encouraging coughing, and close monitoring by arterial blood gases. The patient improved somewhat during the day, becoming less wild. That evening, for the first time, he responded to his name.
The patient was more alert. He was seen again by the surgeons, who felt his abdomen was still soft, without any indications for surgery. His dose of Valium, to contain his agitation, was reduced.
He was seen in the morning by the neurological consult, who felt that he was "still quite obtunded," confused, and disoriented. Nonetheless, his progress since admission was striking. He could answer questions. When asked where he was, he said, "The hospital," though he could not specify which one. When asked his name, he said, "John." He could state his age. He was taken off Valium entirely. His temperature continued to fluctuate in the range of 99° to 101°. Dr. Minna wrote: "He is better in all ways."
Lab values, back from the day before, continued to climb. CPK had now gone to 2900, the highest in the history of the hospital. There was still no explanation for these enzyme changes. The patient continued to improve in responsiveness, though his mental function was far from satisfactory. In answer to questions, he said that one plus one was "one," and two plus two was "five."
He was able to carry out verbal commands such as "squeeze my hand" and "open your eyes." However, for the most part he lay in bed with his eyes closed; he initiated little spontaneous activity, and never spoke except in reply to questions.
His Foley catheter was removed. He was able to urinate in the normal manner. He was more active mentally, and remembered his last name.
Blood cultures now revealed growth of a gramnegative bacillus, identified as bacteroides, probably of bowel origin. The patient was sufficiently improved that he could be questioned about toxins, drugs, mushrooms, work exposure, and possible ingestions of heavy metals; there was no evidence for any of these. He was seen again by the surgeons, who concluded that his abdomen was soft, with normal bowel sounds.
He was seen by the neurological consults, who observed mild proximal muscle weakness and suggested study of the electrical activity of the muscles, by electromyography. He was also noted to have mushy swelling of his extremities.
The patient's mental condition continued to improve. A repeat kidney X ray was read as normal.
There was continued improvement. Enzymes had dropped to near-normal levels. He had no temperature.
Bariuim enema was repeated, in the search for diverticulitis or other source of infection. None was seen.
Electromyography was normal. It was decided to discontinue his chloramphenicol antibiotic and see if he remained without fever.
Chloramphenicol was stopped. The patient did well, taking liquids by mouth.
On his second day off antibiotics, his temperature fluctuated in the range of 101° to 100° F.
The patient had an upper gastrointestinal series of X rays, which were normal. On his third day off antibiotics, the temperature began to spike again, to 102°. Tenderness and guarding of the right upper abdomen reappeared.
The surgeons concluded that the patient had cholecystitis, or infection of the gallbladder, which had probably begun initially as cholangitis, infection of the bile system. They also wondered, however, whether he might have a liver abscess. The patient was restarted on antibiotics.
Mr. O'Connor was transferred from the medical service to the surgical service as a preoperative candidate for exploratory abdominal surgery. His mental state continued to clear slowly.
The neurological consult saw him and agreed that his mental status was improving. The surgeons, however, found that his abdominal tenderness had disappeared with the antibiotics. X rays of the gallbladder showed no filling of the bladder sac, but the films were of poor quality. Radioactive scans of the liver and spleen were negative.
Scheduled operation was canceled in order to allow time for further preoperative studies. A repeated gallbladder X ray definitely showed no filling, although this time the films were of good quality. A celiac angiogram was scheduled.
Day 22 and Day 23
The weekend. Specialized procedures such as celiac angiography could not be done, and further work on the patient was postponed until Monday.
Celiac angiography was performed. Under 1ocal anesthetic, a thin, flexible catheter was passed up the femoral artery in the leg, to the aorta, and finally to the celiac axis, a network of arteries coming off the aorta to supply blood to all the upper abdominal organs. A dye opaque to X rays was injected, and the vessels studied. No space-occupying lesion (tumor) was found, and the vessels were normal in appearance. The patient made a good recovery from the procedure.
The abdomen was soft and nontender. The patient felt well. He was still on chloramphenicol antibiotic. Enzymes were, by now, fully normal.
The patient had no fever and felt well. The surgical staff decided to stop antibiotics, and see if fever and symptoms recurred.
He was taken off antibiotics. Temperature and white-cell count remained normal. The patient himself was in good spirits.
There was no demonstrable worsening of the patient's condition on his second day off antibiotics. His wife expressed the opinion that his mental state was entirely normal once more.
His condition remained stable on the third day. He said he felt well. He had no fever and no elevation in white count.
His condition was still good; his abdomen was soft without tenderness. He said he felt well. It was now clear that he was not an operative candidate. Plans were made for his discharge the next day.
Discharged. His discharge diagnosis was fever of unknown origin with bacteroides septicemia. The opinion of the house staff remained that this patient had probably had bile-collecting-system infection.