CLINICAL ABSTRACT

This is a case of patient CL, 18/F, Filipino, Roman Catholic, from Malaybalay City,
Bukidnon. Admitted on September 16, 2015 at Northern Mindanao Medical Center due
to change in sensorium.

History of Present Illness

8 days prior to admission, the patient had onset of frontal headache associated
with dizziness, nape pain and vomiting of more than 10 episodes of previously ingested
food which was shortly followed by body weakness and change in sensorium. Patient had
no other symptoms such as abdominal pain, change in urinary and bowel habits, no
palpable mass on other body parts, no fever, nor weight loss. There were likewise no
symptoms suggestive of a bleeding disorder since there was no complain of gross
bleeding, petechiae or easy bruisability.
2 days prior to admission, patient now had increased sleeping time associated
with behavioral changes. Consult done at a local hospital with subsequent admission.
Patient was referred to our institution for further evaluation and management.

Past Medical History

Previously admitted at Bukidnon Provincial Hospital for delivery of a term baby
(July 4, 2015) and at Malaybalay Polymedic General Hospital due to recent complain of
change in sensorium (September 15, 2015). No Diabetes Mellitus, Hypertension nor
asthma. No known allergy to food and drugs.

Family History
Patient has a family history of Hypertension. No family history of Diabetes Mellitus
or Asthma.

OB-Gyne History
G1P1 (1001), Delivered to a live, term male baby via normal spontaneous vaginal
delivery at Bukidnon Provincial Hospital.
Physical Examination upon Admission
Vital Signs:
BP-110/80 mm/Hg RR-24 breaths/ min W-45 kgs
HR-82 beats/min T-36.1 degrees Celsius

General Survey: Drowsy, Coherent, Oriented, Glasgow Coma Scale = 14 (E4, V5, M6)
Skin: warm, dry
Eyes: anicteric sclera, pink palpebral conjunctiva
Chest/Lungs: symmetrical chest expansion, clear breath sounds
Cardio-vascular system: adynamic precordium, distinct heart sounds, normal rate, regular
rhythm, no murmur
Abdomen: flat, normoactive bowel sounds, soft, no organomegaly, non-tender
Genito-urinary: grossly female
Extremities: good peripheral pulses, no edema
Neurologic Exam: Cranial nerves and Sensory nerves were not assessed since patient
does not obey commands
Pupils- isocoric @ 5mm
Motor: 3/5 on all extremities. No pathologic reflexes.
Deep tendon reflexes on all extremities = ++

Course in the Wards

On admission, pertinent physical examination findings revealed a patient who is
drowsy but coherent, with 3/5 muscle strength in all extremities and HGT of 121 mg/dL.
On the 1st HD, patient was seen by a Neurologist. His clinical impression was r/o
Connective Tissue Disease, r/o Mass. The following Diagnostics were ordered: ANA,
PTPA, APTT, CT, BT, Cranial CT Scan with Contrast & Angiogram. Medications were
continued. In the afternoon of the 1st HD, she complained of nape pain associated with
hypertension (BP-180/120), she was given Tramadol 50 mg IVTT after which, the BP
went down to 120/90.
On the 2nd HD, despite continued medications, patient still drowsy now with note
of anisocoria. Further diagnostics requested: ESR, CRP, Ca, Mg, VDRL, HBsAg, and
Anti-HCV. Mannitol was increased to 100 cc q 4H and vital signs monitoring increased to
q 1H. On morning of the same HD, patient had an abrupt change in sensorium to GCS 3
(E1M1V1), pupils were now fixed and dilated so she was subsequently intubated. 3 hrs
later, she had supraventricular tachycardia, Verapamil 5 mg IVT given and she was
hooked to a cardiac monitor. 6 hrs after intubation, patient arrested. Cardio-pulmonary
resuscitation was done, patient was revived but supraventricular tachycardia persisted
despite 2 more doses of verapamil 5 mg IVTT. Patient shortly thereafter arrested again,
however despite resuscitative measures, patient eventually succumbed.

Admitting Orders
Admit to P4F2 (Neuro ICU)  P1F3 (Stroke Ward)
Secure consent to care
TPR q 2
Diet: Insert NGT F16, Start OF @ 1,500 kcal/d divided in 6 equal feedings in 1:1 dilution
with the ff breakdown: CHO 225 gm, CHON 75 gm, Fats 33 gm
Diagnostics: CBC, plt ct, Cranial CT Scan (plain)
U/A, CXR PAL view, Blood typing, HGT, APTT, PTPA
Venoclysis: PNSS 1L @ 30 gtts/min
Vital signs with O2 sat q 2 hrs
I & O q shift
SPERM q 6h
Referral to Neuro sub-specialty
Insert FBC F16, attach to urobag
Refer accordingly.
Diagnostic Examination
September 16, 2015:
Complete Blood Count
PARAMETER RESULT UNIT REFERENC PARAMETER RESULT UNI REFERENC
S S E VALUE S S T E VALUE
White Blood 10.77 x10^3 4.4 – 11.0 Neutrophils 85.30 % 43.4 – 76.2
Cells /uL
Red Blood 4.70 x10^6/u Male: 4.5 – Lymphocytes 10.70 % 17.4 – 48.2
Cells L 5.9
Female: 4.5
– 5.1
Hemoglobin 13.60 g/dL Male: 14.0 – Monocytes 4.00 % 4.5 – 10.5
17.5
Female:
12.3 – 15.3
Hematocrit 38.20 % Male: 41.5 – Eosinophils 0.40 % 1.0 – 3.0
50.4
Female:
35.9 – 44.6
MCV 81.30 fL 80.0 – 96.0 Basophils 0.00 % 0.0 – 2.0
MCH 28.90 pg 27.5 – 33.2 Bands/Stabs 0 % 0-5
MCHC 35.60 g/dL or 33.4 – 35.5
%
Platelets 361 x10^3/u 150.0 –
L 450.0

Blood Chemistry
Test Results Reference Values
Blood Urea Nitrogen 17.39 mg/dl 10 - 50 mg/dl
Creatinine 0.57 mg/dl 0.6 - 1.2 mg/dl
Potassium 4.40 mmol/L 3.5 - 5.3 mmol/L
Sodium 137.85 mmol/L 135 - 148 mmol/L

Immunology
Test Result
ANA (Anti-nuclear Antibody) Negative

Prothrombin Time:
Protime 9 seconds
Control 12.30 seconds
I.N.R. 0.73
APTT (Activated Partial Thromboplastin Time)
APTT 32.90 seconds
Control 28.9 seconds

Chest X-ray
NO SIGNIFICANT CHEST FINDINGS

September 17, 2015

Urinalysis
PHYSICAL
PROPERTIES
Color Straw Clarity Hazy
Specific Gravity 1.020 PH 6.5
MICROSCOPIC EXAM
Epithelial Cells Few Pus (WBC) 3-5/hpf
RBC 54-56 Bacteria Moderate

September 18, 2015:

Chest X-Ray AP Lateral
NODULAR DENSITY, RIGHT PARACARDIAC AREA- RIGHT LATERAL VIEW OR CT SCAN
CORRELATION IS SUGGESTED FOR FURTHER EVALUATION.
ET TUBE IN PLACE.

ABG
Patient Temperature: 37.0
Patient Hemoglobin: 13.6
Corrected: Measured:37 Reference Ranges
37.0
PH 7.45 7.45 7.350-7.450
pCO2 33 33 35.0-45.0 mmHg
pO2 115 115 80-100 mmHg

HGT – 140 mg/dL (random)