General Data  ACM  4/F  DOB:  Brgy. Holy Spirit, Quezon City  Filipino  DOA:

Cyanosis Chief Complaint

History of Present Illness  Diagnosed case of Severe communicating hydrocephalus, post-meningitic (2010, NCH). Advised to underwent shunting but deferred several times due to growth on CSF. Last CSF analysis done was on Sept 2010 at NCH. Maintained on phenobarbital at 4mkd; Regular follow-up with NCH.  2 days PTA  (+) nonproductive cough and colds  (+) fever (tmax 37.9C), given paracetamol  Good appetite  1 day PTA  (+) cough and colds, (-) fever  Noted decreased activity; hence, consult at NCH. Prescribed with cefuroxime.  Day of admission  Difficulty of breathing: alar flkaring; Circumoral cyanosis  consult at private clinic  PCMC

Birth and Maternal History  Born to a 27 y/o G4P5 (3205), nonsmoker, non-alcoholic beverage drinker; 2 prenatal checkups starting 5mos AOG at LHC. (+) SVI at 2mos AOG, took paracetamol. No other illnesses. No exposure to viral exanthems, radiation.  Delivered preterm (32 weeks), twin pregnancy, via NSD at EAMC  Admitted at EAMC NICU as neonatal sepsis, pneumonia x 3 months. Work-up included CUTZ which revealed hydrocephalus.

Feeding History  Prenan 2-3oz q3hours  Complementary feeding at age 6 months  Soft diet, milk per orem

Immunization History  HepB, DPT x 2 doses  OPV x 3 doses

Growth and Development  Poor head control

Past Medical History  Severe communicating hydrocephalus secondary to post-meningitic changes; Cerebral palsy, quadrispastic  At age 3-4 months at NCH. Regular follow-up at NCH  s/p Vent tap x 2; Last CSF analysis (Sept 2010): (+) growth (Staphylococcus, Streptococcus), treated with Vancomycin, Oxacillin, PipTazo  Oct 2010: seizures (upward gaze, jerking of upper extremities); last seizure: September 2012  Maintained on Phenobarbital (4mkd)  For shunting  Pneumonia  October 2012 at NCH

Family History

PHYSICAL EXAMINATION General SurveyLimp, Generalized pallor Vital SignsBP 0  0 CR 0  100 RR 0 AnthropometricsWt 11 kg (z0) HC 58cm (>p98) HEENTMacrocephalic, pupils 4mm NRTL, moist oral mucosa, (-) CLADS Chest and LungsNo spontaneous respiration; (+) crackles CardiovascularAdynamic precordium, regular rhythm, no murmur AbdomenFlat abdomen, soft, (-) masses, liver edge 5cm below right subcostal margin ExtremitiesCold extremities, poor pulses, CRT 3-4secs Neuro GCS3 CNs: 4mm NRTL; (-) Doll’s eye; (-) Corneals; (-) Facial asymmetry; Poor gag; Tongue midline Poor muscle tone; No spontaneous movement No nuchal rigidity

Aspiration Pneumonia; t/c Sepsis Severe Communicating Hydrocephalus sec to Post-meningitic; Cerebral Palsy Quadrispastic; s/p Arrest Admitting Diagnosis

Course in the Wards

10/14 9:30AM BP 0 CR 0 RR 0 Limp, generalized pallor No spontaneous respiration No spontaneous movement CPR x 20 minutes Epinephrine (1:10000) q3mins 10AM BP 0 CR 120  130 No spontaneous respiration Cold extremities, poor pulses, CRT 3-4s CBC: Hgb122, Hct38, WBC3.3, seg35, lymp58, baso3, mono3, eos1, Plt219 ABG: pH 6.8 pCO2 43 pO2 57 Urinalysis: light yellow, hazy, spgr 1.006, pH 7, glucose +4, protein +2, RBC 7, WBC 4, epith 15, occ bacteria, few amorphous phosphates Intraosseous access PNSS 20ml/kg x 3 RSI, ET (size 5, level 13) Epinephrine drip (1) Plan to start Piptazo, Amik Ref to RICU, Surgery, PIDS Seen by RICU NaHCO3 22meqs

10/14 10:20AM SBP faint 140 CR 130s RR on CAB (-) Doll’s eye (+) crackles Fair pulses Electrolytes: Na119 K2.9 Cl 83 Ca1.76 RBS 17.9 BUN 1.3 Crea 37 Total Bili 0.12/ Direct 0/ Unconjugate 0.12 Total prot 50/ Albumin 27/ Globulin 23/ AGRatio 1.2 ALT 1538 AST 1873 Dopamine (15) Hydrocortisone (50/BSA) Voluven 10ml/kg  reassess, if ok  PNSS 1.5mtn KCl 5 meqs (KIR 0.3) Calcium gluconate 10% 10ml q8 x 3doses Once available: #1: NaCl 3% at 65ml/hr x 1hr #2: PNSS – hold After 1 hr: #1: 3%NaCl at 11ml/hr #2: PNSS at 33ml/hr + KCl 6meqs (KIR 0.3) 10/14 11:15AM GCS 3 Afebrile Pupils 3mm nrtl No spontaneous respiration (+) rales Cold extremities PIDS: Start Piptazo (240), Amik (15) 10/14 11:30AM *No available antibiotics yet Ampicillin (70)

10/14 11:33AM BP 0 CR 40s BP 0 CR 0 4mm NRTL No corneals No spontaneous respiration 10/14 11:43AM CPR x 10mins Epinephrine 1:10,000 q3mins DNR/DNI Pronounced dead. Post mortem care rendered