General data T.A. 9/M Filipino Bulacan DOB: 25 September 2005 DOA: 25 December 2014 ER Stay: 2 hours

Altered sensorium Chief complaint

History of present illness Patient was apparently well until… 2 days PTA (+) back/flank pains (+) headache, frontal area (+) vomiting: nonbilious, nonbloody, nonprojectile, x ~10 episodes, ¼ - ½ cup per bout (-) cough, colds, loose stools, dysuria, hematuria, seizures Consult done at a hospital and was subsequently admitted Work-up done CBC: 115.6/34/20.8/seg86/lym8/343 UA: yellow/sl hazy/7.0/1.015/neg/neg/1-2/15-19 Leukocytes +2 Moderate bacteria Na133.3/Cl 105.4/K 3.65 Dx: UTI Tx: Cefuroxime IV

History of present illness 1 day PTA While admitted, (+) febrile episodes Later noted with altered sensorium: combative behavior  no verbal response A> CNSI, probably bacterial Advised further workup; however, decided to go on HAMA  PCMC

Birth and maternal history Born to a 25-year old G3P3 (2012) nonsmoker, non-alcoholic beverage drinker with regular prenatal check-up at VRP MC starting 1 mo AOG. No known illnesses during pregnancy. (+) UTZ at 1st and 2nd trimester: normal. (+) multivitamins, FeSO4. No exposure to radiation and viral exanthems. (-) abortifacients Delivered FT via LTCS secondary to repeat at VRP MC assisted by an OBGyn. Noted with good cry and activity. No cord coil, MSAF. NBS, HS: normal

Feeding history Complementary feeding at 6 months Picky eater; fond of eating hotdog, fried chicken, sweets

Immunization history BCG; 3 doses x HepB, DPT, OPV, HiB Measles MMR No boosters

Growth & development At par with age

Past medical history Diagnosed with asthma at age 4 years; admitted at VRP MC; (+) pleural effusion noted, CT Scan done Last asthma attack in 2011

Family history 40 OFW 34 office 13 5 PKI, treated

Course in the wards

12/25 3:20AM Obtunded GCS 7 (E2V1M4) Bp 150/100  100/60 Cr 95, RR 20, T37C, 99% Anisocoric pupils (5mm OD, 2mm OS) SCE, (+) harsh breath sounds AP, no murmur Flat abdomen, soft Warm extremities, full pulses 3:40AM On CAB 90/60, 105, 36.9C (-) alar flaring (+) fresh blood/ET (+) coffee ground/NGT CBC: 118/38/24.8/seg93, lymp3, mono4/503 PT: 15/11.5/61.2%/1.3 PTT: 28.9/28.4 Hgt 134 Na 134, K 4.2, Cl 91, Ca 2.51 BUN 3.5 Crea 43 Alt 12, Ast 19 RBS VBG: pH 7.37, pCO2 29, pO2 65, sO2 92%, HCO3 16.8 CXR: Normal chest **For TAGS, TACS, Blood CS **For Cranial CTScan plain & contrast CNS Infection probably bacterial meningitis vs TB meningitis ET size 6 level 18 D5NSS mtn NPO Omeprazole (1) IFC Ceftriaxone  start Ampicillin (300) while awaiting approval Referred to PICU, Neuro, PIDS NaHCO3 50meqs (3)

12/25 3:40AM Seen by ICU HR 150-160s, intubated Pupils 2mm (+) crackles BLF (-) murmur Flat abdomen Warm ext, full pulses (-) rashes, petechiae (-) seizures, bleeding Funduscopy: right: e/n; left: small ror Seen by Neuro 120/80, 140, CAB, 38.4C Right 3mm SRTL, Left 2mm SRTL (-) bicrorneal reflex (+) Babinski, B; (-) clonus DTR ++/++ (-) nuchal rigidity TPAG: 81/46/35/1.3 **For CSF Analysis **For PPD CNSI, TB meningitis vs viral encephalitis

12/25 4:57AM Desaturation (40%) CR 150-160s ↓ CR 0 BP palp40  0 Fixed dilated pupils 5:13AM CR 0 BP 0 t/c Uncal herniation secondary to a probable intracranial mass High quality CPR Epinephrine 1:10,000 (1) q3mins Postmortem care For complete autopsy

t/c uncal herniation probably secondary to intracranial mass Mortality diagnosis

Provisional anatomic diagnosis Cerebellar hemorrhage, left. Pulmonary congestion with focal hemorrhage, bilateral. Pulmonary adhesions, right upper lung.