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Washington University Experience | VASCULAR | Herniation, uncal | 2A0 Case 2 History
Case 2 History ---- The patient was a 64 year old woman admitted on 2/15 and expired later the same day. Her past medical history was significant for a modified right radical mastectomy 8 years prior for infiltrating ductal carcinoma. Recent mammograms revealed an increased density in her left breast. Bone scan showed destructive lesions of spinous processes of T10, L1, L3, and a questionable lytic lesion at L5 thought to represent metastatic disease. The patient was begun on DES and later switched to Tamoxifen. Repeat liver spleen scan showed a poorly defined lesion in the left lobe of the liver. An abdominal CT scan was normal. The patient remained well until a few days prior to admission when she developed a right frontal headache. Later she complained of a severe right orbit pain. Her son found her sitting on the floor later that evening, slumped against the wall. The patient remained conversive but drowsy, vomited one time and was noted to have unusual grasping movements of both hands. An ambulance was dispatched, finding the patient unconscious on the floor with unreactive pupils. At the BJH ER the patient was unresponsive with no spontaneous movement, left sided extensor posturing to noxious stimuli, bilateral papilledema with retinal hemorrhages and fixed mid-position pupils. She received Decadron by IV push and Mannitol. A neurology consult described a comatose elderly woman with Cheyne-Stokes respirations and weak extensor posturing of the extremities (L>R). There were no responses to OCM's or ice water calorics. Pupils were 4/4 and unreactive to light without response to corneal stimulation or facial grimace. Reflexes were 1 to 2+ and both toes were upgoing in response to the Babinski maneuver. Laboratory exam was not contributory. Stat CT scan showed a right frontal lobe hemorrhage with rupture into the right lateral ventricle and midline shift from the right to the left. The patient remained comatose with pupils 4 mm's irregular and unreactive until her death later that day.
