General Data

ABL

7/F

DOB: 4/16/07

Penaranda, Nueva Ecija

Filipino

DOA: 10/06/14

SeizureChief Complaint

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

Birth & Maternal Hx Nutritional Hx Immunization

HxGrowth 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 weekFormula fed starting 2 wks til 1 year with BonamilComplementary feeding at 5monthsNon picky eater

“Complete” vaccines c/o LHCBCG; 3doses of HepB, DPT, OPV; MeaslesNo boosters

At par with age No previous hospitalizations, trauma, surgery

Family History

PHYSICAL EXAMINATION

Vital Signs BP 90/60 CR 120 RR 20s T 38.9

Anthropometrics Wt 17.5 kg (z0) HC

HEENT AS, PPC, moist buccal mucosa

Chest and Lungs SCE, (-) retractions, clear breath sounds

Cardiovascular Adynamic precordium, regular rhythm, no murmur

Abdomen Flat abdomen, soft, (-) masses

Extremities Warm extremities, full pulses, CRT <2s

Neuro

GCS 6 (E1V2M3)CNs: 2-3mm RTL; (+) doll’s eye; intact corneals; no facial asymmetry; fair gag; tongue midlineSpastic lower extremities > upper extremities;Withdraws from painHyperrefelexive; (+) nuchal rigidity

CNS Infection, Viral encephalitis vs TB Meningitis

Course in the Wards

10/6/14 2AMGCS 5 (E1V1M3)90/60 120s 25 38.9AS, PPC, 2-3mmRTL pupilsSCE, CBSAP, no murmurSoft, flat abdomenSpastic extremities

CBC: 112/33/9.9 (seg77, lymph15, baso 1, mono 7), plt 287

PT12.40/11.2/81.5%/1.11PTT34.3/30.3

Na139 K3.6 Cl102 Ca 2.19BUN 3.9Crea 47RBS 6.5

Blood CSTAGS: No organismTACS

D5NSS mtnNPORSIET (size 5.5, level 16)PIDS: CeftriaxoneRICU, Neuro

10/6 2:40AMSeen by Neuro

A> Viral encephalitis probably Japanese B Encephalitis

Phenobarbital (3mkd)Elevate head 30-40degInsert foley catheter

For EEG; CSF Analysis

10/6 3:30AMSeen by ICUIntubated due to decreased sensoriumWith spontaneous respirationPartial eye opening90/60 86 afebrilePupils 2-3mm ERTLGood air entry, clear breath soundsFlat abdomenFull pulses

Regulate CAB at20-30cpmOmeprazole (1)

10/6 6:30AM ABGpH 7.33/pCO2 25/ pO2 304/sO2 100/HCO3 13.2/BEB -11.1

Metabolic acidosis, uncompensated

NaHCO3 (0.3)

10/6 8:10AM PIDS: Start Ceftriaxone (100)

10/6 10AM60/30, 180sGaspingCold extremities, poor pulses, CRT <2s↓Palpatory 70Poor distal pulses

Hgt 202 PNSS 20ml/kg bolus x 4

Dopamine (5)

10/6 11:40AMFixed dilated pupilsPalpatory 60, 180sWarm extremitiesParents appraised

Voluven 20ml/kg bolusNorepinephrine(.5)Dopamine (10)

10/6 12NNs/p PNSS bolus x 5Ongoing voluvenPalpatory 60 160s 98%Fixed dilated pupils(-) CornealsWarm extremitiesCompressible pulses

Dopamine (15)

10/6 12:45PMGCS370/40Pupils 5mm fixed dilated(-) doll’s eye(-) corneals

Seen by NeuroParents appraisedFor cranial CT scan once hemodynamically stable

10/6 1PM110/60 150 99%Fixed dilated pupilsWarm extremitiesGood distal pulses

IVF (mtn)

10/6 3:30PMGCS 385/50 34 97%Pupils 4-5mm NRTL(-) doll’s eye; (-) cornealsFair pulses

Cranial CT Scan: Cerebral edema

CNSInfectionTB Meningitis vs Viral encephalitis

IVF x 1 hour: TFR5#1: 3% NaCl#2: PNSSAfter 1 hour, TFR 1For PPD, CSF Analysis

10/6 4:20PM80/40 80/50

Dopamine (20)

10/7 12:30AM Na K2.2 KCl 6 meqs (KIR 0.23)

10/7 4AM PT 14.5, 11.261.3%INR 1.3

PTT 41.8, 27.6

Vit K x 1doseIVF: hold NaClD5.45 + KCl (KIR 0.2)HL

10/7 9:40AM(-) doll’s eyeFixed dilated pupilsCold extremitiesFair pulses

Na 189 K 2.5 Cl153 Ca1.85

Regulate bagtube ventilationCalcium gluconate 10%Hydrocortisone (2)

10/7 12NNGCS 3BP not appreciated, CR 120Poor central pulses↓CR 0 BP 0

CPR x 15minsEpinephrine (1:10000)q3minsEpinephrine drip (1)