NATIONAL ACADEMICS AND RESEARCH COMMITTEE

APMC-SN National Clinico-Pathologic Case Competition 2015

NCR Chapter
Clinical Abstract
This is a case of M.L., 34 y/o, G9P8 (8018), married, Filipino, and female from Laguna who
consulted due to right-sided body weakness.
Past Medical History
Unremarkable
Family History
(+) asthma: paternal side.
Personal and Social History
Patient is a housewife. She is a non-smoker and non-alcoholic beverage drinker.
Obstetric and Gynecological History
The patient is a G9P8 (8018) mother. All 8 children were allegedly born full term via normal
spontaneous vaginal delivery at home by a hilot. Four (4) months PTC, the patient was allegedly
on the 5th month of her 9th pregnancy when she began to have profuse vaginal bleeding. She
sought consult at a local hospital where she underwent dilatation and curettage. Assessment was
unknown to the patient. She was discharged and purportedly improved. Two (2) months PTC,
there was noted recurrence of vaginal bleeding. She again sought consult at the same hospital
where she underwent another dilatation and curettage. Bleeding ceased for weeks however
recurred 1 month PTC.
Review of Systems
(+) Cough
(+) Nape pains

(+) Chills
(+) Irritable

(+) Headache, R occipital

Physical Examination on Admission

The patient was received at the ACU with the following physical examination findings:
Drowsy, (+) eye opening on name calling, obeys command, no verbal output
Blood pressure: 160/90, Heart Rate: 118, Respiratory Rate: 22 Temperature: 36.8 C

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Anicteric sclerae, pink palpebral conjunctivae, (-) cervical lymphadenopathies, (-)

anterior neck mass
Equal chest expansion, clear breath sounds
AP, NRRR, no murmurs
Flat abdomen, normoactive bowel sounds, no tenderness

Neurological Exam
CN II: Pupils 3 mm EBTRL, fundoscopy: distinct disk borders
CN III, IV, VI: (-) visual threat, (+) preferential gaze to the left
CN V: Brisk corneals
CN VII: (-) facial asymmetry
CN IX, X: weak gag reflex
CN XII: tongue midline
Motor Exam: RUE and RLE 0/5 LUE and LLE 5/5
Sensory Exam: no deficits
DTRs: +3 on all extremities
Cerebrals: No nystagmus, No dysmetria
Meningeals: Supple neck
Autonomic: No incontinence
Course in the ward
On the 1st hospital day, CBC and blood chemistry were requested. She underwent cranial CT
scan where the following findings were noted:
4 x 4 cm left frontal cortical hemorrhage with surrounding edema; minimal spillage into
the 3rd ventricles up the 4th ventricles, (+) slight midline shift.
On the 2nd hospital day, the patient had the following PE:
Awake, conscious, coherent, can follow command, moans
Pupils 3-4 mm EBRTL
Preferential gaze to the left
Sluggish corneals, diminished sensation on the right side of the face
Shallow naso-labial folds, right
Tongue deviation, right
Motor Exam: RUE 0/5 RLE 1/5 LUE and LLE 4/5
A transvaginal UTZ was performed revealing the following findings:

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Uterus anteverted with smooth contour and heterogeneous echopattern measuring 8.5 x
5.4 x 7. The endometrium is hypoechoic measuring 0.5 cm with distinct simple
endometrial hyperplasia. There is highly vascular heterogeneous mass 2 x 2.2 x 1.6 cm
within posterior myometrium. The right ovary measures 2.3 x 2.4 cm. The left ovary
measures 5.9 x 2.9 with multiple unilocular cysts. Largest cyst measures 2.9 cm. There is
no fluid in the CDS.

On the 3rd hospital day, the patient was noted to have anisocoria and decreased sensorium. PE
findings were:
Stuporrous, (+) flexion movement of upper extremities, no eye opening
BP: 140/90 HR: 88 RR: 18
Pupils: OD 4-5 mm NRTL, irregular
OS 6 mm NRTL, irregular
(+) shoulder shrug R>L
(+) abdominal breathing
(+) corneal reflex, OU
(+) gag reflex
The patient was hyperventilated using mask with subsequent intubation. Despite medical
decompression, the patients condition progressed. A stat cranial CT scan (plain and contrast)
was done revealing the following findings:
Resolving hematoma, left frontal but with vasogenic edema causing severe midline shift
compressing the left lateral ventricle.
New recent/acute hematoma 4 x 3 x 3 cm (18 cc), left temporoparietal area causing uncal
herniation. Midbrain compressed by mass effect from the left TP hematoma.
The patient at this point was already noted to have decerebrate posturing to pain.
On the 4th hospital day, the patient was noted to be comatose with anisocoric pupils. She no
longer has any motor response to pain. She was also noted to have passage of coffee-ground
material per NGT. She was tachycardic (HR: 180) and febrile (T: 40.4C). The patients BP was
noted at 30 palpatory. Dopamine drip was started. Twenty (20) minutes later, she went to code.
Advanced cardiovascular life support administered however, she was no longer revived.

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Laboratory Results
Hematology
WBC (x109/L)
RBC (x1012/L)
Hgb (g/L)
Hct
MCV (fL)
MCH (pg)
RDW-CV (%)
Ptt (x109/L)
Neut
Lym
Mono
Eos
Baso
ESR (mm/h)

On admission
19.21
2.83
75
0.235
265
319
15.8
333
0.903
0.069
0.024
0.003
0.001
-

4th hospital day

27
1.3
33
0.124
95.4
24.5
17
284
0.78
0.17
0.03
0.02
82

NV
4.5-11
4.2-5.4
120-160
0.38-0.47
80-100
27-31
11.5-15
150-450
0.5-0.7
0.2-0.5
0.02-0.09
0-0.06
0-0.02
0-20

Chemistry
Glc (mmol/L)
BUN (mmol/L)
Crea ( mol/L)
Na (mmol/L)
K (mmol/L)
Cl (mmol/L)
Ca (mmol/L)
Albumin (g/L)
AST (IU/L)
ALT (IU/L)
Control/Pt

On admission
10.25
4.58
67
147
3.5
108
2.31
30
45.8/31/3

3rd hospital day

8.66
65
61
105
-

NV
4.1-6.6
2.9-9.3
57-113
136-144
3.6-5.1
101-111
2.23-2.58
35-48
15-41
17-63