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

3. Altered sensorium
Chief complaint

4. 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

5. 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

6. 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

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

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

9. Growth & development
At par with age

10. 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

11. Family history 40
OFW 34
office 13 5
PKI, treated

12. Course in the wards

13. 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)

14. 12/25 3:40AM
Seen by ICU
HR s, 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

15. 12/25 4:57AM
Desaturation (40%)
CR s ↓
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

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

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