1. Case Management

2. Patient Information Salas, Wilkie 2 y.o./M W11B19 88 th Hospital Day Chief Complaint: Enlarging Head, inability to support upright posture and loss of neck control

3. History: Chief Complaint: 6 mos PTA: noted gradual enlargement of head (-) consults 5 mos PTA: persistence and progression of symptoms  consult at local hospital: ultrasound revealed hydrocephalus, referred to PGH 2 weeks PTA: consult at PGH-Pedia DOPS: CT scan revealed posterior fossa mass, advised admission (August 13, 2009)

4. Review of Systems (+) seizures(+) enuresis (-) headache(+) weakness (+) loss of consciousness(+) decreased sensorium (+) weight loss Past Medical History: (+) Neck abscess (2008) s/p incision & drainage (2008) Maternal History: Patient born full-term to a then G2P1 22 year-old mother via SVD in a hospital, (-) fetomaternal complications

5. Assessment Posterior Fossa Tumor: Primitive Neuro-ectodermal Tumor VS Choroid Plexus Papilloma s/p shunt insertion Nosocomial pneumonia, resolved Nosocomal sepsis, resolved New-onset pneumonia, resolved s/p tracheostomy tube reinsertion (10/13/2009) Atelectasis

6. Physical Examination General Conscious, (+) tracheostomy tube in place, easily agitated, (-) regard, NICRD VitalsBP 90/60HR 130RR 32Temp: afebrile AnthropometricsHt/Lt:Wt:Head Circ: 57cm HEENT Pink palp conj, anicteric sclerae, (+) CLAD, (+) 1cm grade 1 ulcer (L) occipital area Chest/LungsECE, CBS, (+) crackles – bilateral lung fields CVS Adynamic precordium, distinct heart sounds, normal rate and rhythm, (-) murmur AbdomenSoft, flabby, NABS, (-) tenderness, (-) organomegaly, GUI Essentially normal grossly male genitalia, uncircumcised, tanner 1 Skin & ExtremitiesFull & equal pulses, CRT < 2s, (-) cyanosis

7. NeurologicGeneral: E2V1M5. (-) regard, arousable, unable to sustain wakefulness Cranial Nerves: I : cannot be assessed II : 4mm, sluggishly reactive to light OU III, IV, VI : (-) Doll’s reflex V : sluggish corneals VII : (-) facial asymmetry/weakness VIII : cannot be assessed IX, X : cannot be assessed XI : good shoulder tone XII : cannot be assessed Motor: 0/5 on all extremities, (+) spasticity, (-) rigidity DTRs: 3+ on all extremities Sensory: Withdraws to pain on nail pinching Meningeals: (-) Kernig’s Cerebellar: (-) nystagmus (+) Babinski, bilateral

8. Course in the Wards 08/13: Admitted for management of Posterior Fossa Tumor 08/13 – present: Multiple history of nosocomial sepsis s/p intubation s/p tracheostomy 09/’09: noted decreasing sensorium GCS 15  increased sleeping time  GCS8  GCS 6 10/13: s/p tracheostomy intubation 10/27: explanation of prognosis, signing of DNR, deferred from all surgical interventions 10/01: (+) episode of tachypnea, Mother verablized: “Parang ayaw ko yata na DNR siya”

9. Hospice Referral 10/19: Referred for Terminal Care Disposition: For discharge, on CPAP Discharge pending acquisition of CPAP mask, O2 tank, etc.

10. Patient Issues (+) occasional Cough (+) occasional fever (-) pain, (-) discomfort

11. Reception with Parents Initially, met with good reception, (+) note of apprehension upon informing re: Hospice Referral Mother provided needed information voluntarily Suceeding meetings: avoidant attitude, increasing anxiety Discordant behavior: Says their “OK” but facial expression & actuations show uneasiness Shrugs off attention: “No need, we’re OK.” “I’ll talk to you later.”; “I already talked to the pedia…” Cooperates to some extent when prodded Father of patient warmer, treads on wife’s behavior