allergies: patient recorded as having no known allergies to drugs attending: chief complaint: unresponsive. major surgical or invasive procedure: none. history of present illness: the pt is a 27 year old right handed woman with cell disease who became acutely unresponsive on the day of admission, taken to an osh where head ct showed large intraparenchymal hemorrhage, likely thalamic in origin, with bilateral intraventricular extension and herniation. she was transferred to for further evaluation. per the pt's mother, pt at baseline has been mute and has relied on a wheelchair for mobility since her stroke in . today, she was straining on the toilet for many minutes, afterwards was carried by her father to the couch when suddenly she appeared dazed, then eyes rolled back and she became unresponsive. no gtc activity or incontinence. ems was called and she was intubated in the field. at the osh, she was loaded with 1 gm dilantin and given a total of 8 mg ativan for presumed status epilepticus. ct was performed, and then she was given 50 gm mannitol and transferred to . here, neursurgery was consulted immediately and based on the poor prognosis of the extensive bleed they declined any neurosurgical intervention. past medical history: - cell disease -stroke at age 7, leaving her with l hemiparesis, which largely resolved with pt, and also a mild mental retardation -stroke at age 24, leaving her wheelchair bound, aphasic, j tube dependent, incontinent of urine, dependent on her parents for her adl's, started on coumadin at that time, then switched to lovenox -diagnosed with last year -partial complex seizures since stroke in . -multiple aspiration pneumonias in past two years social history: the pt. lives at home with her parents, reliant on them for adl's since , has 7 year old son, finished high school. family history: son has trait vs disease, as does a cousin. physical exam: vitals: afebrile, hr 83, bp 125/78, rr 16 on simv gen: intubated, unresponsive heent: mmm neck: supple cv: rrr with 2/6 sem at lsb resp: cta b abd: soft, nt/nd j tube in place ext: warm, well perfused skin: no rash or trauma ms: no spontaneous mvmts, no response to voice or deep stim cn: l pupil 5mm, r pupil 3 mm both fixed. absent dolls, sluggish l corneal, absent r corneal. weak gag. motor: increased tone throughout, most prominent in lue. overall decorticate posturing. no withdrawal or movement to pain in all four ext, triple flexion in feet bilaterally. reflexes: tri br pat ach plantar l 3 3 3 3 2 up r 2 2 2 3 2 up pertinent results: 09:45pm blood wbc-22.2*# rbc-2.10* hgb-7.9* hct-23.1* mcv-110*# mch-37.5*# mchc-34.2 rdw-20.7* plt ct-421 09:45pm blood pt-13.6* ptt-31.0 inr(pt)-1.2 09:45pm blood glucose-169* urean-14 creat-0.5 na-142 k-3.8 cl-105 hco3-25 angap-16 09:45pm blood calcium-9.1 phos-3.9 mg-1.7 11:12am blood phenyto-14.5 04:26am blood type-art po2-133* pco2-34* ph-7.45 calhco3-24 base xs-0 : head ct without iv contrast: there is a large intraparenchymal hemorrhage centered within the left thalamus with marked left to right subfalcine herniation and surrounding mass effect and edema. there is blood present within all the ventricles and there is marked dilatation of the ventricular system, which is stable since the prior examination. no new areas of intraparenchymal hemorrhage are demonstrated. there is also indistinctness of the and white matter within the left frontal lobe, likely secondary to surrounding mass effect from the large intraparenchymal hemorrhage. visualized paranasal sinuses and mastoid air cells are clear. surrounding osseous and soft tissue structures are unremarkable. impression: large left thalamic intraparenchymal hemorrhage with intraventricular extension and hydrocephalus. there is marked left to right subfalcine herniation, which appears stable in the interval. : findings: the large left thalamic hemorrhage appears stable in size but slightly increased in density in its medial portion, which may be related to the technical differences between the two studies. extensive mass effect with severe shift of the septum pellucidum and third ventricle to the right does not appear significantly changed. a large amount of blood remains present in the lateral ventricles, left greater than right, as well as in the third and fourth ventricles. the lateral ventricles remain dilated. evaluation of the right frontal lobe is slightly limited by ct calibration artifact. indistinctness of the /white matter interface is again noted in the left frontal lobe and possibly also in the right frontal lobe. the visualized osseous structures and paranasal sinuses appear unchanged. impression: 1. stable extent of left thalamic hemorrhage with large intraventricular component and severe associated mass effect. 2. stable indistinct appearance of /white matter interface in both cerebral hemisphere could be related to old infarcts and periventricular edema. brief hospital course: the pt is a very unfortunate 27 year old female with cell disease, secondary , and now very large thalamic hemorrhage with intraventricular extension and sulcal effacement. examination on admission demonstrated absent pupillary, corneal reflexes, weak gag, and posturing in all four extremities, suggestive of severe cerebral damage. neurosurgery has declined any surgical intervention given the patient's poor prognosis. after extensive discussion with the family, pt was a full code on admission, despite her grave prognosis. over the course of the first two hospital days, she was managed with mannitol, dilantin, labetolol, fever control, ativan prn. as the pt showed signs of deterioration (loss of gag reflex, completely ventilator-dependent), a brain death examination was performed on hospital day three. the pt failed all parts of the examination, including the apnea test and cold calorics. she was pronounced brain dead. the organ bank was notified but the pt was deemed an unsuitable candidate for organ donation. she was taken off of all life support measures and passed away on hospital day three. a post-mortem examination was declined by her next of . medications on admission: -temazepam -promethazine -famotidine -reglan -folate -oxycodone -trileptal -ativan -senna -lexapro -morphine prn -nutrin feeds discharge medications: none. discharge disposition: expired discharge diagnosis: -intracranial hemorrhage discharge condition: deceased discharge instructions: n/a followup instructions: n/a md, Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Transfusion of packed cells Diagnoses: Obstructive hydrocephalus Other convulsions Moyamoya disease Intracerebral hemorrhage Other late effects of cerebrovascular disease Late effects of cerebrovascular disease, aphasia Mild intellectual disabilities Sickle-cell disease, unspecified