Cranial nerves: (illegible phrase) … pupils dilated and unresponsive. Absent corneal reflex.
Square-Wave Nerve Stimulator: Persistent although decreased function of the peripheral nerves.
Cerebral Spinal Fluid (CSF): Atraumatic puncture, clear fluid, opening pressure 125 mm of water.
EEG: Flat wave in all leads.
IMPRESSION: (illegible sentence), (illegible phrase) … with no localizing signs … (illegible phrase) … coma due to diffuse cerebral edema is the primary diagnosis. The possibility of a cerebral vascular accident or stroke cannot be ruled out without cerebral angiography. An idiosyncratic response to any of the agents used for anesthesia remains a possibility although I believe … (illegible phrase). Pneumoencephatography and/or a CAT scan may be of help but I believe it would be of academic interest only and would not provide any additional information for diagnosis in this difficult case. The EEG with its suppression of all organized and otherwise activity certainly suggests extensive brain death or damage. This same picture has been seen with tranquilizer/ alcohol combinations but it is extremely rare. There are only three cases in the literature. Whatever the cause, this patient has suffered an acute insult to the brain. There is no chance that this patient represents any degenerative neurological syndrome.
Thank you very much for letting me see this very interesting patient.
DR. CAROL HARVEY, resident, neurology
Susan cursed the handwriting as she surveyed the many blanks on her own notebook sheet. She took another sip of coffee and turned the page in the chart. On the next pa® was another note from Dr. Harvey.
February 15, 1975. Follow up by Neurology
Patient status = unchanged. Repeat EEG = no electrical activity. CSF laboratory values were all within normal limits.
IMPRESSION: I have discussed this case with my attending and with other neurology residents who agree on the diagnosis of acute brain insult leading to brain death. It is also the general consensus that cerebral edema from acute hypoxia was the immediate cause of the problem. The cause of the hypoxia was probably some sort of cerebral vascular accident perhaps due to a transient blood clot, platelet clot, fibrin clot, or other embolus related to the endometrial scraping. Some sort of acute idiopathic polyneuritis or vasculitis may have played a part. Two papers of interest are: “Acute Idiopathic Polyneuritis; a Report of Three Cases,” Australian Journal of Neurology, volume 13, Sept. 1973, pp 98-101.
“Prolonged Coma and Brain Death Following Ingestion of Sleeping Pills by Eighteen Year Old Female,” New England Journal of Neurology, volume 73, July 1974, pp 301-302.
Cerebral angiography, pneumoencephalography, and a CAT scan can be done, but it is the combined opinion that the results would be normal.
Thank you very much
DR. CAROL HARVEY
Susan let her aching hand rest for a few moments after copying the lengthy neurology notes. She moved on in the chart, passing the nurses’ notes until she reached the laboratory results. There were numerous X-ray reports, including a normal series of skull X-rays. Next came the extensive chemistry and hematology reports, which Susan laboriously copied into her notebook pages. Since all the results were essentially normal, Susan concentrated on finding out if there were any changes between the pre-op values and the post-op values. There was only one value that fell into this category; after the operation Nancy Greenly had exhibited a higher serum sugar as if she had developed a diabetic tendency. The serial EKGs were not very revealing, although they did show some nonspecific S and ST wave changes following the D&C. However, there was no pre-op EKG to compare.
Finishing, Susan closed the cover of the chart and leaned back, stretching her hands up toward the ceiling. At the very limit of her stretch, she grunted and exhaled. She leaned forward and glanced over the eight pages of minute handwriting which she had just completed. She felt no further in her investigation but she did not expect to. Much of what she had copied she really did not understand.
Susan believed in the scientific method and she believed in the power of books and knowledge. For her there was no substitute for information. Although she did not know very much about clinical medicine, she had the positive feeling that by combining method with information she could solve the problem at hand—why had Nancy Greenly lapsed into coma. First she had to gather as much observational data as possible; that was the purpose of the charts. Next she had to understand the data; for that she must turn to the literature. Analysis leading to synthesis: pure Cartesian magic. Susan was optimistic at this stage. And it did not faze her that she did not understand much of the material she had taken from Nancy Greenly’s chart. She felt confident that within the maze of information were critical points which could lead to the solution. But to see it Susan needed more information, a lot more.