long case 1801006051

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT        

CHIEF COMPLAINTS:

27 year old male patient presented with history of electric shock

HISTORY OF PRESENTING ILLNESS:

The patient was alright 9 months ago.

On July 10th the patient got drunk with friends and was dropped off by his friends nearby his house late at night around 10 p.m.

After some time, his friend passing the road saw him stuck and hugging the pole.

He wasn't responding when called, so his friend tried to pull him away from the pole.

when he tried to touch the pt, he felt an electric shock.

Then he was rushed to a nearby hospital where it was found that he was in cardiac arrest, following which a successful CPR was done, and he was put on a ventilator for around a day.

The Dr noticed that he was in a Vegetative state and referred him to another hospital

At the other hospital, a tracheostomy was done, and he stayed there for 45 days. He contracted an infection with pseudomonas and S. pneumonia and was treated accordingly

All feeding was done through the Ryles Tube.

He was then admitted into another hospital where his condition slightly improved ( able to blink eyes , make eye contact, open mouth) but he was still fed by Ryles tube

He was discahrged and 3 months after the incident he had seizure episodes

No of episodes :- around 10 times

Duration:- 3 to 5 minutes

Treatment given :- Levitarecitam

Patient with his family approached to our hospital to take advice on removal of his tracheostomy tube

PAST HISTORY: 

He had several episodes of seizures 3 months after the electric shock.

No history of  Diabetes, hypertension, asthma, tuberculosis,thyroid anomalies 

FAMILY HISTORY:

Not significant

PERSONAL HISTORY

Appetite: decreased

Diet : liquified food is given through ryles tube 

Usually given foods are rice, dal with water.

Sleep: Adequate

Bowel and Bladder: Regular 

Addictions: Used to drink alcohol and smoke occasionally 

TREATMENT HISTORY:

Suction every 2 hourly.

Change in position every 2 hours.

Vitals monitoring every 4 hrs.

Tab RANITIDINE 150 mg PO/OD (morning before food)

T. LEVITARECITAM 500mg PO/OD (Night time)

T. SUPRA CAL [ CALCIUM CITRATE+VITAMIN K2-7+ CALCITRIOL ]PO/OD (after lunch)

GENERAL PHYSICAL EXAMINATION :

The patient is in a vegetative state, uncooperative, appears thin, weak, and malnourished

Pallor-absent 

Icterus-absent 

Cyanosis-absent 

Clubbing-absent 

Lymphadenopathy-absent 

Pedal edema- absent

Koilonychia- absent

Burn scar present on left palmer surface due to electric scar.

VITALS:-

Temperature: 98°F

Pulse rate: 100 beats per minute 

Respiratory rate:20 cycles per minute 

Bp:105/80

Spo2: 98%

SYSTEMIC EXAMINATIONS

CENTRAL NERVOUS SYSTEM 

GCS :- E4 V2 M4 At the time of examination

Higher mental functions 

Patient is disoriented and is in vegetative state 

Memory and speech could not be assessed.

Intellect cannot be assessed

Release reflexes 

Grasp reflex:- couldn't be performed as patient kept his fists clenched

Glabellar reflex:- Absent

Pout reflex:- Absent

Palmo-mental reflex:- Couldnt be performed as patient kept his fists clenched

Cranial nerve examination

Pupillary reflex: Direct (present) 

         

                               Indirect(present)

Corneal and conjunctival reflexes are present 

Gag reflex is present 

Motor System :- 

                             Right                                    Left

                     UL               LL                     UL             LL

Bulk        wasted        wasted            wasted      wasted

Tone    hypertonia    normal       hypertonia    normal

Power :-   3/5                 3/5                3/5              3/5

Reflexes:- 

 Biceps, Triceps, and Supinator reflexes are absent 

 Knee reflex positive in both limbs

 Ankle reflex positive in both limbs

plantar reflex positive in both limbs

sensory system: could not be elicited

myoclonic jerks are seen regularly

Gait: could not be elicited

CARDIOVASCULAR SYSTEM :

S1 and s2 are heard 

No murmurs are heard 

Trachea - central with tracheostomy tube 

RESPIRATORY SYSTEM:

Bilateral basal crepitations are heard .

ABDOMINAL EXAMINATION:

Soft and non tender 

liver and spleen not palpable

INVESTIGATIONS:

XRAY NECK

XRAY CHEST 

PROVISIONAL DIAGNOSIS:

Hypoxic ischemic brain injury post cpr state

TREATMENT PLAN:

After a neurology consultation neurologist suggested family counseling and palliative therapy