Cc: Headache/Seizure
Patient is a known case of Spinal cord
compression sec to neuroblastoma st IV
(spine), s/p colostomy with biopsy (Sept
2019), s/p adjuvant chemotherapy; s/p
partial resection (Aug 2020, PCMC) s/p
radiotherapy x 2 cycles (Aug-Sept 2021),
S/P Cycle 1 Chemotherapy (9/17/21).
Patient was previously admitted at Onco
ward 10/11-20/21 due to Urinary Tract
Infection and cellulitis on left posterior
thoracic area, given with Cefuroxime. Oral
Chemotherapy also started last admission.
Discharged well and stable with home
medications such as cotrimoxazole,
metoclopramide, etoposide, paracetamol,
morphine, pregabalin and dexamethasone.
Apparently well until 2 days prior to consult,
upon awakening, patient experienced
headache, occipital area, localized,
described as "parang sinusuntok", no other
associated symptoms such as fever, cough,
colds, vomiting, abdominal pain, increase
sleeping time, changes in sensorium. No
consultation was done. Maintenance
medication continued
1 day prior to admission, no noted
headache.
10hrs prior to consult, upon awakening,
noted crying due to recurrence of
headache, occipital area, localized, still no
other associated symptoms, given
Morphine with relief of symptom.
3hrs prior to consult, still with headache,
same character as above, BP was taken
noted elevated at 160/100 and suddenly
had seizure episode, described as shaking
of upper extremities, upward rolling of
eyeballs, teeth grinding, perioral cyanosis,
cyanosis of fingernails, about 10minutes in
duration, brought to Taytay Doctors
Hospital, with BP 130/100, RR27, HR 130,
febrile at 38.1, still on active seizure, hence,
given with diazepam 5mg TIV, still with
seizure. Given with midazolam 2.5mg,
noted resolution of seizure woth post ictal
drowsiness. Advised admission, but mother
opted THOC, hence brought in our
institution
Last seizure: 10/31 1pm
ROS: no cough, colds, abdominal
distention, blurring of vision
PMH: Patient is a known case of Spinal
cord compression sec to neuroblastoma st
IV (spine), s/p colostomy with biopsy (Sept
2019), s/p adjuvant chemotherapy; s/p
partial resection (Aug 2020, PCMC) s/p
radiotherapy x 2 cycles (Aug-Sept 2021),
S/P Cycle 1 Chemotherapy (9/17/21).
Patient was previously admitted at Onco
ward 10/11-20/21 due to Urinary Tract
Infection and cellulitis on left posterior
thoracic area, given with unrecalled
antibiotics. Oral Chemotherapy also started
last admission. Discharged well and stable
with home medications such as
cotrimoxazole, metoclopramide, etoposide,
paracetamol, morphine, pregabalin and
dexamethasone. Under the care of
Palliative Service
FH: (+)Asthma and HPN on maternal side,
denies other heredofamilial diseases
DH: Supposedly at Grade 3, stopped due
to his current condition but patient is able
to write, read, answers simple calculations,
unable to walk since August 5, 2021 due to
spinal cord compression
PSH: only child, usually spends time by
playing cellphone games, drawing, writing
etc.
PE:
Awake, with spontaneous eye opening, not
in distress
BP 120/90 HR 120 RR 24, T 36.5, 99%
Anicteric sclerae, pink palpebral
conjunctivae, no naso-aural discharge,
moist lips, non hyperemic tonsils
Symmetric chest expansion, (-) retractions,
clear breath sounds
Adynamic precordium, regular rhythm, ()murmur
Non distended abdomen, normoactive
bowel sounds, (+)colostomy, right
hemiabdomen, soft
No Stunting, No Wasting
F:
On D5 0.3 NaCl at MR
Initially on NPO
R:
No dyspnea, no fast breathing, no cough,
no colds
Symmetrical chest expansion, no
retractions, clear and equal breath sounds
RR 20s, O2 sat 99% on room air
I:
With 1 episode of fever last night max temp
38.1, no recurrence thereafter
Temp ranges: 36.6-37.4
Full pulses, CRT<2sec, warm extremities
NEURO PE: spontaneous eye opening,
withdraws to pain, moans to pain
CNI - unable to assess
CNII- isocoric, 3-4 pupils mm EBRTL
(+) Doll’s eye
CNV - intact facial sensation
CNVII-no facial asymmetry
CNVIII: unable to assess
CN IX X- intact gag
Motor: withdraws to pain on upper
extremities
Sensory: withdraws to pain on upper
extremities
DTR: 1 on upper extremities, 0 on lower
extremities
No nuchal rigidity , no meningeal signs
Bilateral clonus, no babinski, no nystagmus
Currently on the 1st HD
being managed as a case of
Status Epilepticus secondary to
Hypertensive Encephalopathy; Probable
Brain Metastasis; Spinal Cord
Compression secondary to Neuroblastoma
Stage IV (spine); R/O Sepsis; S/P
colostomy with biopsy (Sept 2019), S/P
Adjuvant Chemotherapy; S/P partial
resection (Aug 2020, PCMC) s/p
radiotherapy x 2 cycles (Aug-Sept 2021),
S/P Cycle 1 Chemotherapy (9/17/21, NCH);
CBC: (post ictal)
Hgb 158, Hct 47,
wbc 40.1 seg 88, lym 10 plt 339
CRP <6mg/L
Awaiting Blood CS results
Still for Urinalysis / Urine GSCS and
Fecalysis / Stool CS
*COVID NPS GENEXPERT: POSITIVE*
Current Antibiotics:
Ceftriaxone 2grams q12 max dose D1
C:
BP: 100-110/70-80, HR 130s
Adynamic precordium, tachycardic, regular
rhythm, no murmurs, no neck vein
distention, warm extremities, pulses full
and equal, no cyanosis, no edema
H:
No pallor, no bleeding
CBC:
Hgb 158, Hct 47,
wbc 40.1 seg 88, lym 10 plt 339
M:
No vomiting, no loose stooling, no
abdominal distention, on colostomy
Na: 141, K: 4.6, Cl: 102, Ca: 2.54
BUN: 10.0
Crea: 36
ALT 666.8 (16x)
AST 187.7 (4.6x)
HGT ranges: 81-82-145
Meds:
Morphine 0.25mkdose q4 IV PRN
Lactulose 2.2G/5ml, 30cc ODHS
O:
Diazepam 0.3mkd PRN
Mannitol 5cc/kg q6
D:
Initially on NPO
May have full diet once fully awake
Plans
May have full diet once fully awake
D5.3NaCL at MR
Diagnostics:
For repeat CBC today
I: IVF: ~1500
Oral: ~ 30-50cc
O: unquantified
3 diaper changes since admission
(Medium sized adult diaper, moderate-fully
soKed)
For procalcitonin, d dimer, serum ferritin,
LDH
Awaiting official results of Cranial CT scan
with Contrast and CXR AP-L
Awaiting Blood CS
Still for:
U/A, Urine GS/CS
F/A, Stool Culture
BM: 3x colostomy changes
N:
Can maintain wakefulness
No recurrence of seizure
No recurrence of headache
spontaneous eye opening, and movement
of extremities
CNI - unable to assess
CNII- isocoric, 3-4 pupils mm EBRTL
(+) Doll’s eye
CNV - intact facial sensation
CNVII-no facial asymmetry
CNVIII: gross hearing intact
CN IX X- intact gag
Motor:, withdraws to pain on upper
extremities
Sensory: reacts to light and deep touch
withdraws to pain on upper extremities
DTR: 1 on upper extremities, 0 on lower
extremities
No nuchal rigidity , no meningeal signs
Bilateral clonus, no babinski, no nystagmus
Meds:
Phenytoin 5mkday q6 - maintenance
Therapeutics:
1. Ceftriaxone 100mkday q12
2. Paracetamol 10mkdose q4 PRN
3. Phenytoin 20mkdose as LD then
5mkday q6
4. Diazepam 0.3mkd PRN
5. Morphine 0.25mkdose q4 IV PRN
6. Mannitol 5cc/kg q6
7. Zinc Sulfate 55mg/5ml, 5ml PO BID
8. Cholecalciferol 2000iu/cap 1 cap OD
For transfer to COVID 1 ward
For swabbing of mother
Thank you po.