DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: This (XX)-year-old girl was diagnosed to have a malignant ependymoma. She had had several relapses, and she is admitted now because of new-onset seizures. Her most recent neurosurgery for relapse of the tumor had been in late September, at which time she had craniotomy and removal of some but not all of the tumor. She had been left with dense right hemiplegia and had undergone physical rehabilitation. She had felt well enough to go to oncology camp and had gone on the camp bus the day before admission, did well that evening, was reported well the morning of admission. Then, at about 2 p.m., at camp, she had right-sided focal seizures.
She was taken to a local emergency room and stabilized and then brought for further workup. A detailed history and physical was done. She was described as having a postictal state before she received Dilantin and Ativan in the local emergency room.
PHYSICAL EXAMINATION: HEENT: On admission, she had no obvious facial asymmetry. Her extraocular movements were symmetrical as usual. She had no evidence of infection. LUNGS: Clear. HEART: Normal. ABDOMEN: Globular and soft. She had no lymphadenopathy or hepatosplenomegaly. NEUROLOGIC: She had dense right spastic hemiparesis.
LABORATORY DATA: She had laboratory values including Dilantin level of 15, hemoglobin 10.6, white count 8200, platelet count 354,000, 69 polys, 1 band, 22 lymphs, 5 monos, 2 eos, 1 basophil. Hepatic function studies were completely normal with SGOT 13 and SGPT 12. Basic metabolic profile was not particularly remarkable. Creatinine 0.9, BUN 12, glucose 126, calcium 9.4, total protein 6.8, and normal sodium and potassium.
IMAGING STUDIES: In addition to her physical examination and laboratory values, a CT scan of the head with and without contrast was done late on the night of admission. It was compared to the MRI that had been done before. A large enhancing tumor was seen in the left frontal and temporal lobes. It seemed to be at least as large as it was in December.
Note that she had had tumor resection in late September. However, there was new hydrocephalus with significant enlargement of the lateral and third ventricles. These findings were consistent with obstruction at the level of the sylvian aqueduct with mild midline shift to the left.
It was realized that she needed to have a VP shunt. Her usual surgeon was not available. However, the covering neurosurgeon accepted her in transfer. The transfer team from the pediatric ICU came to get the patient and took her for neurosurgery. She was taken via ambulance to have the surgery done.
DISCHARGE DIAGNOSIS: Relapsed ependymoma with seizures and obstructive hydrocephalus.
