THE CASE

CL, 63/F
 CL, 63/F
• NORZAGAY, BULACAN
• PREVIOUSLY AMBULATORY
• & INDEPENDENT IN ACTIVITIES
• IN DAILY LIVING
 CL, 63/F
• NORZAGAY, BULACAN
• PREVIOUSLY AMBULATORY
• IN DAILY LIVING
• & INDEPENDENT IN ACTIVITIES

CHIEF COMPAINT:
SUDDEN LOSS OF CONSCIOUSNESS
 HISTORY OF PRESENT ILLNESS

3 MONTHS PRIOR TO CONSULT

CL presented with generalized weakness associated with

occasional dizziness and headache. She was admitted twice in
a local hospital, where she was managed as a case of
pneumonia and gastritis, with unrecalled medications. A CT
scan was done on her first admission, which was allegedly
unremarkable. Symptoms allegedly also improved upon
discharge.
 HISTORY OF PRESENT ILLNESS

AT THE INTERIM

Patient still presented with occasional episodes of dizziness

and headache. No consult was done.
 HISTORY OF PRESENT ILLNESS

O N THE DAY OF ADMISSION

The patient presented with sudden loss of consciousness

lasting for a few seconds. Upon awakening, a decrease in
sensorium was noted by family members. Copious secretions
from the X were also noted. She was brought to a local
hospital, where she was managed as a case of cerebro-vascular
accident–infarct, to consider a space-occupying lesion. She was
eventually referred to a tertiary institution for further
evaluation and management.
 (+) HYPERTENSION,
POOR COMPLIANCE
PAST MEDICAL (-) DIABETES MELLITUS
HISTORY
(-) ASTHMA/ALLERGY TO FOOD
& DRUGS

(+)TUBERCULOSIS, TREATED IN 1980S

(-) HEART/LUNG/LIVER/KIDNEY DISEASE

(-)CANCER
 (-)HYPERTENSION

(-) DIABETES MELLITUS FAMILY MEDICAL

HISTORY
(-) ASTHMA/ALLERGY TO FOOD
& DRUGS
(-)TUBERCULOSIS

(-) HEART/LUNG/LIVER/KIDNEY
DISEASE
(-)CANCER
 NON-SMOKER

NON-ALCOHOLIC DRINKER

NO KNOWN HISTORY OF
ILLICIT DRUG USE
PERSONAL
AND SOCIAL
HISTORY
 REVIEW OF SYSTEMS

(-) BLURRING OF VISION (-) JAUNDICE

(-) CHEST PAIN (-) ODYNOPHAGIA
(-) PAROXYSMAL NOCTURNAL (-) VOMITING
DYSPNEA (-) BM CHANGES
(-) 1-PILLOW ORTHOPNEA (-) DYSURIA
(-) ABDOMINAL PAIN (-) GROSS HEMATURIA
(-) DYSPHAGIA (-) NOCTURIA
(-)WEIGHT LOSS (-) PALLOR
(-) PERIPHERAL EDEMA (-) PETECHIAE/ECCHYMOSES
 ON ER ADMISSION

• Stuporous (E3V2M5)
• BP 100/60, HR 65, RR 26, 36.4°C
• Anicteric sclerae, pink conjunctivae,
(-)neck vein engorgement
• Equal chest expansion, (+) crackles,
bilateral lung fields
PHYSICAL • Adynamic precordium, distinct heart
EXAMINATION sounds,
• regular rhythm
• Soft, non-tender abdomen; (-)palpable 

masses, (-) organomegaly
• Full and equal pulses, pink nailbeds,
capillary

refill time <2 seconds
• (-) edema/cyanosis/clubbing
 ON ER ADMISSION

• 3 mm equally brisk and reactive to

light
• No facial asymmetry
NEUROLOGIC • Intact gag reflex
EXAMINATION • Motor examination: localizes to pain
on all extremities
• Sensory examination: no gross
deficits
COURSE IN THE HOSPITAL

DAY

Patient was seen by the Emergency Medicine resident with a GCS

Score of E3V2M5, in respiratory distress. No facial asymmetry and
sensory or motor deficits noted.

CT Scan: a prepontine/clival mass lesion with extension and mass

effect; obstructive hydrocephalus
COURSE IN THE HOSPITAL

DAY

1
She was intubated and hooked to a valve-bag mask.

MEDICATIONS:
Piperacillin-tazobactam 4.5g IV
Azithromycin 500 mg/tab

Patient was referred to the Neurosurgery Service (NSS).

COURSE IN THE HOSPITAL

DAY

2
Patient was seen by the Neurosurgery Service. She was assessed to
have a GCS of E3VTM5, and was admitted to the NSSCU, where she
was hooked to a mechanical ventilator.

MEDICATIONS:
Azithromycin was stopped.
Mannitol 150 cc IV Q4 and Omeprazole 40mg IV OD were added.
COURSE IN THE HOSPITAL

DAY

3
GCS score improved to E4V1M6. She was able to answer yes or no
questions. Left lateral rectus palsy was noted.

The impression of the primary service, NSS, was obstructive

hydrocephalus secondary to a cerebellopontine angle mass.

Mechanical ventilator settings were SIMV 360, FiO2 60%, and back-up
rate of 14. Medications were maintained.

PLAN: Ventriculo-peritoneal shunt insertion

COURSE IN THE HOSPITAL

DAY

3
Patient was referred to General Medicine for clearance and was
assessed to have a high clinical risk for a high surgical risk operation,
but no objection if deemed life- or limb-saving.

Patient was also referred to Pulmonary Medicine, and was noted to

have bilateral rhonchi, more prominent on the left.

CHEST X-RAY: reticulonodular infiltrates

COURSE IN THE HOSPITAL

DAY

3
The assessment at the time was acute respiratory failure secondary
to aspiration pneumonia, central.

MEDICATIONS:
Paracetamol 300mg IV Q4 PRN for fever.
N-acetylcysteine 600mg/tab BID, and Chlorhexidine oral care TID
were added.
COURSE IN THE HOSPITAL

DAYS

4-6
The patient was awake and able to answer questions. Her potassium
on the 5th day was 2.7mmol/L, prompting potassium correction,
resulting in a potassium of 4.9 on the 7th day.

BLOOD CS: Gram-positive cocci in pairs x 2 sites

The mechanical ventilator was maintained on SIMV settings.

Pulmonary Medicine suggested referral to Infectious Disease.
COURSE IN THE HOSPITAL

DAY

Patient underwent VPS insertion.

COURSE IN THE HOSPITAL

DAY

8
At around 4am, there was note of fecaloid output per NGT. The
patient was also noted to be tachypneic. The patient was referred to
General Surgery. On examination, her vitals were BP 90/60mmHg,
HR 79, and RR 12. She had a slightly distended abdomen with soft,
normoactive bowel sounds. Chest x-ray PA and plain abdominal x-
ray, upright were requested.
COURSE IN THE HOSPITAL

DAY

8
At 7:48 am, the patient had hypotensive episodes before presenting
with a BP = 0 and HR = 0. She was resuscitated with a BP 50/30 and
was hooked to norepinephrine and dopamine drips. At 8:30 am, she
was seen by the General Surgery service and was found to have a
GCS score of E V M . Other findings include a nontender abdomen,
1 T 6

normoactive bowel sounds, and no guarding.

COURSE IN THE HOSPITAL

DAY

8
11 am, CHEST X-RAY: no pneumoperitoneum

General Surgery advised the primary service to consider ileus as the

source of recurrent NGT output, and signed out noting that no
invasive procedure was indicated at that point.

Two hours later, the patient presented again with a BP = 0 and HR =

0. ACLS was done but failed to revive the patient. The patient
eventually expired and consent for autopsy was secured.
 COMPLETE BLOOD COUNT

TEST REF DAY1 DAY 8 TEST REF DAY1 DAY 8

WBC 4.50-11.0 x 109/ 12.90 9.20 RDW 11.0-16.0 14.5 15.5

L
RBC 4.2-5.4 x 10 /L
12
4.53 4.21 PLATELET 150-450 x 305 4.21
10 /L
9

HGB 120-160 g/L 133 122 NEUT 0.50-0.70 0.92 122

HCT 0.38-0.47 0.40 0.40 LYMPH 0.20-0.50 0.05 0.40

MCV 80-96fL 87.3 94.9 MONO 0.02-0.09 0.03 0.02

MCH 27.0-31.0pg 29.4 29.0 EOSINO 0.00-0.06 0.00 0.00

MCHC 320-360g/L 337 306 BASO 0.00-0.02 0.00 0.00

 TEST REF DAY1 DAY5 DAY7 DAY8

BUN 2.5-6.1mmol/L 5.5 6.2

CREA 46-92umol/L 70 41 120

ALBUMIN 35-50umol/L 39 19

2.10-2.55
CALCIUM 2.30 2.41
mmol/L
137-145 mmol/
SODIUM 135 139 138 139
L

POTASSIUM 3.5-5.1 mmol/L 3.6 2.7 4.9 4.8

BLOOD
CHEMISTRY CHLORIDE 98-107 mmol/L 90 109

0.7-1.00 mmol/
MAGNESIUM 0.76 0.89 1.37
L
0.81-1.49
PHOSPHORUS 3.85
mmol/L

FBS 4.1-5.9 mmol/L 8.4(rbs)

AST 14-36 U/L 20 249

ALT 21-71 IU/L 30 237

 URINALYSIS REF DAY1 DAY7

COLOR Dark yellow Orange brown

TRANSPARENCY Slightly hazy Turbid

BILIRUBIN <17 umol/L Negative +2

UROBILINOGEN <35 umol/L +2 +4

KETONE <1.5 mmol/L Trace Negative

GLUCOSE <2.8mmol/L Normal Normal

ALBUMIN <0.3 g/L Negative +1

BLOOD <5 erys/uL Negative +1

PH 6.0 5.0

NITRITE Negative Negative Negative

 URINALYSIS REF DAY1 DAY7

LEUKOCYTES <25 leukos/ uL Negative +1

SPECIFIC GRAVITY 1.018 1.050

RBC 0/uL 0 13

WBC 0-9/uL 0 13

EPITHELIAL CELLS 0-5/uL 0 0

BACTERIA 0/uL 268 264

MUCUS THREAD 0-5/uL 361 4

YEAST CELLS 0 4

CASTS 0 Granular, 0

Calcium
CRYSTALS 0-6
oxalate,1012
MICROBIOLOGIC
STUDIES DAY2 DAY4 DAY7

POSITIVE FOR GRAM (+)

BLOOD GS/CS COCCI IN PAIRS AFTER A:15/
B:13 HOURS INCUBATION

NO ORGANISM
SEEN, NO PMN, NO
CSF GS/ INDIA INK
ENCAPSULATED
ORGANISM SEEN
NO GRAM (-)
DIPLOCOCCI YEAST
CELLS, HYPHAL
ELEMENTS, GRAM
ETA GS/CS (+) COCCI IN PAIRS,
GRAM (+) IN
CHAIN, GRAM (-)
BACILLI, GRAM (+)
BACILLI

NO ACID-FAST
ETA AFB
BACILLI SEEN
 DAY3 DAY8

PH 7.506 7.063

PCO2 29.3 30.0

P02 117.2 187.4

HCO3 23.4 8.9

ARTERIAL
BLOOD BE 1.7 -19.8
GAS
OSST 99.0 99.1

TCO2 24.4 9.9

SBC 25.9 9.8

 DAY3

PT-REFERENCE 12.5

PT-TIME 13.1

PT% 86.9

COAGULATION
STUDIES PT-INR 1.05

APTT-
28.2
REFERENCE

APTT-TIME 23.8
 OTHER LABORATORIES

REF DAY7 DAY8

TROPONIN I
<15,6 63.0
HS

BLOOD TYPE 0+

CSF TP 0.12-0.6g/L 0.10 (L)

CSF GLUCOSE 2.2-3.9 mmol/L 4.60 (H)

CSF COLORLESS, CLEAR, 0RBC,

QUALITATIVE 0WBC