2. General Data  ABL  7/F  DOB: 4/16/07  Penaranda, Nueva Ecija  Filipino  DOA: 10/06/14

3. Seizure Chief Complaint

4. History of Present Illness  Patient is apparently well until…  2 days PTA  (+) Fever (38.5C) given paracetamol (10mkd) with lysis of fever  Decreased appetite and oral intake  Good activity  1 day PTA  Persistence of fever and poor intake  Consult at Medicare  Change in behavior noted  Given Cefuroxime, Ranitidine; Still febrile hence opted transfer  Transferred to Gonzales GH  Episodes of stiffening of extremities and arching of the back  Given Diazepam (0.2) IV, Phenobarbital (15)  Px slept for 30 mins; however, upon waking, noted recurrence of stiffening of extremities  Opted transfer to Manila  In transit, noted multiple episodes of stiffening of extremities x 5sec with 5-15 mins interval. Given O2 support

5. Birth & Maternal HxNutritional HxImmunization Hx Growth and Developmental Past Medical History Born to a 29yo G1P1 (1001) mother, nonsmoker, non- alcoholic beverage drinker. Regular PNCU at LHC. No known illnesses. No hazardous exposures. Delivered FT via NSD at home asstd by TBA. Good cry and activity. No MSAF, cord coil. Exclusively breastfed x 1 week Formula fed starting 2 wks til 1 year with Bonamil Complementary feeding at 5months Non picky eater “Complete” vaccines c/o LHC BCG; 3doses of HepB, DPT, OPV; Measles No boosters At par with ageNo previous hospitalizations, trauma, surgery

6. Family History

7. PHYSICAL EXAMINATION Vital SignsBP 90/60 CR 120 RR 20s T 38.9 AnthropometricsWt 17.5 kg (z0) HC HEENTAS, PPC, moist buccal mucosa Chest and LungsSCE, (-) retractions, clear breath sounds CardiovascularAdynamic precordium, regular rhythm, no murmur AbdomenFlat abdomen, soft, (-) masses ExtremitiesWarm extremities, full pulses, CRT <2s Neuro GCS 6 (E1V2M3) CNs: 2-3mm RTL; (+) doll’s eye; intact corneals; no facial asymmetry; fair gag; tongue midline Spastic lower extremities > upper extremities; Withdraws from pain Hyperrefelexive; (+) nuchal rigidity

8. CNS Infection, Viral encephalitis vs TB Meningitis

9. Course in the Wards

10. 10/6/14 2AM GCS 5 (E1V1M3) 90/60 120s 25 38.9 AS, PPC, 2-3mmRTL pupils SCE, CBS AP, no murmur Soft, flat abdomen Spastic extremities CBC: 112/33/9.9 (seg77, lymph15, baso 1, mono 7), plt 287 PT12.40/11.2/81.5%/1.11 PTT34.3/30.3 Na139 K3.6 Cl102 Ca 2.19 BUN 3.9 Crea 47 RBS 6.5 Blood CS TAGS: No organism TACS D5NSS mtn NPO RSI ET (size 5.5, level 16) PIDS: Ceftriaxone RICU, Neuro 10/6 2:40AM Seen by Neuro A> Viral encephalitis probably Japanese B Encephalitis Phenobarbital (3mkd) Elevate head 30-40deg Insert foley catheter For EEG; CSF Analysis

11. 10/6 3:30AM Seen by ICU Intubated due to decreased sensorium With spontaneous respiration Partial eye opening 90/60 86 afebrile Pupils 2-3mm ERTL Good air entry, clear breath sounds Flat abdomen Full pulses Regulate CAB at20-30cpm Omeprazole (1) 10/6 6:30AMABG pH 7.33/pCO2 25/ pO2 304/sO2 100/HCO3 13.2/BEB -11.1 Metabolic acidosis, uncompensated NaHCO3 (0.3) 10/6 8:10AMPIDS: Start Ceftriaxone (100)

12. 10/6 10AM 60/30, 180s Gasping Cold extremities, poor pulses, CRT <2s ↓ Palpatory 70 Poor distal pulses Hgt 202PNSS 20ml/kg bolus x 4 Dopamine (5) 10/6 11:40AM Fixed dilated pupils Palpatory 60, 180s Warm extremities Parents appraised Voluven 20ml/kg bolus Norepinephrine(.5) Dopamine (10) 10/6 12NN s/p PNSS bolus x 5 Ongoing voluven Palpatory 60 160s 98% Fixed dilated pupils (-) Corneals Warm extremities Compressible pulses Dopamine (15)

13. 10/6 12:45PM GCS3 70/40 Pupils 5mm fixed dilated (-) doll’s eye (-) corneals Seen by Neuro Parents appraised For cranial CT scan once hemodynamically stable 10/6 1PM 110/60 150 99% Fixed dilated pupils Warm extremities Good distal pulses IVF (mtn) 10/6 3:30PM GCS 3 85/50 34 97% Pupils 4-5mm NRTL (-) doll’s eye; (-) corneals Fair pulses Cranial CT Scan: Cerebral edema CNSInfection TB Meningitis vs Viral encephalitis IVF x 1 hour: TFR5 #1: 3% NaCl #2: PNSS After 1 hour, TFR 1 For PPD, CSF Analysis 10/6 4:20PM 80/40  80/50 Dopamine (20) 10/7 12:30AMNa K2.2KCl 6 meqs (KIR 0.23)

14. 10/7 4AMPT 14.5, 11.2 61.3% INR 1.3 PTT 41.8, 27.6 Vit K x 1dose IVF: hold NaCl D5.45 + KCl (KIR 0.2) HL 10/7 9:40AM (-) doll’s eye Fixed dilated pupils Cold extremities Fair pulses Na 189 K 2.5 Cl153 Ca1.85Regulate bagtube ventilation Calcium gluconate 10% Hydrocortisone (2) 10/7 12NN GCS 3 BP not appreciated, CR 120 Poor central pulses ↓ CR 0 BP 0 CPR x 15mins Epinephrine (1:10000)q3mins Epinephrine drip (1)