CASE PROTOCOL GENERAL DATA A.P., 40 years old, Male , Single , Filipino, Roman Catholic, unemployed residing in Gen.

Tinio, Nueva Ecija CHIEF COMPLAINT: RIGHT EAR PAIN AND DIZZINESS HPI 3 months PTA, patient complained of dizziness, generalized headache, occasional vomiting and right ear pain. There was no fever, cough/colds, blurring of vision, ottorhea, tinnitus, rhinorrhea, changes in sensorium, history of head trauma. No consult was done, no medications taken. months, worsening of symptoms were noted. This prompted consult with a private MD in Gapan. Patient was diagnosed to have ear infection, prescribed with Levofloxacin 500mg OD x 1 week and Betahistine 16mg BID prn to which he was compliant. However, no follow up was done.

During the interim, patients symptoms improved. Patient went back to his daily activities. However, few days after, there was recurrence of previous symptoms this time with ear discharge, right. No consult was done, the patient took his previous medications. 2 weeks PTA, there was worsening of symptoms despite oral medications. There was more pronounced headache, dizziness, frequent vomiting and severe ear pain. Patient also noted decreased hearing on the R ear. He was observed to have ataxic gait. Consult was done at Gapan District Hospital where he was subsequently admitted. Informant recalled they were told that the patient had ear infection that worsened, now extending to his brain. He was started on IV Ceftriaxone, Tramadol, Ranitidine. However, the patient opted for HAMA after 2 days.

1 week PTA, at home, patient still w/ headache, dizziness, vomiting, ear pain and this time facial swelling, L. There was profuse ear discharge. He was observed to be always in bed, needing assistance from his family to get around.

Persistence of these symptoms prompted consult at PJG Cab, hence admission.

PAST MEDICAL HISTORY

Patient is non Hypertensive, non Diabetic, non Asthmatic with no know allergies to food nor medications. He was not exposed to any chemicals or noxious agents.

PERSONAL AND SOCIAL HISTORY Smoker, 20PY. Occasional alcohol drinker. Elementary Graduate. Unemployed. Lives with his sister and her family in Gen. Tinio, NE. Frequently swims at the river to get woods for cooking. FAMILY HISTORY Both parents died of stroke at old age as complication of poorly controlled hypertension. PHYSICAL EXAMINATION Patient seen at the ER, wheel-chair borne, medium- built, weak-looking, conscious, coherent but irritable BP : 110/80 CR : 78 bpm RR : 18 bpm Temp : 37 C

Integuments : (-)rashes, (-)petechia ENT : (-)icterisia (-)anterior neck mass (-)neck vein engorgement lymphadenopathies, (+)ear discharge, purulent, R ear with swelling Chest/Lungs : (+)SCWE (-)retractions (-)wheezes (-)crackles Cardiac : (+)regular rhythm (+)PMI at 5th ICS, midclavicular line, (-)murmurs Abdomen : flat, normoactive bowel sounds, non-tender, non-rigid, no palpable mass noted Extremities : full and equal pulses, (-)edema(-)clubbing NUERO EXAM Cerebrum : Oriented to person, place and time. Irritable. (-)cervical

Cerebellar : unable to fully examine due to patient being uncooperative (-) Nystagmus Gait N/A, patient not able to stand up

CRANIAL NERVES CN II: pupils 2-3 ertl CN III,IV, VI : Intact EOM ; Positive direct and consensual reflex CN V : (+)corneal reflex CN VII: firm buccal muscles CN VIII : hearing impaired at R ear CN IX,X : (+) gag reflex CN XI: can shrug shoulders CN XII: tongue midline Motor : Intact Sensory : Intact Babinski : negative

DIAGNOSTICS CBC: Hgb 156/ Hct 0.42/WBC 17.47/N77L15M8/Plt 392 Urinalysis: Yellow/Cloudy/5.0/1.030/S neg/P neg/PC 0-1/RC 0-1 FBS 4.6 (3.9 - 6.1 mmol/L) BUN 8.0 (2.9 - 8.2 mmol/L) Crea 78 (53 - 106 umol/L) Chole 4.6 (3.88 6.47 mmol/L) TG 1.09 (0.11-2.15 mmol/L) Na= 145.9 K= 4.38

CXR-PA view: Unremarkable

CT scan w/ contrast Multiseptated mass in the right cerebellum meas. About 3.0x5.0x4.0cm (LxWxAP) effacing the 4th ventricle and adjacent cerebellar folia Consider abscess formation