27 YEAR OLD MALE WITH HYPOXIC ISCHEMIC ENCEPHALOPATHY
My sincere thanks to Dr. Saptarshi.
https://ssahamedicalcases.blogspot.com/2023/01/patient-history-pt-is-27-yrs-old-male.html
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
Discharge Date
Date:20/03/2023
Diagnosis
HYPOXIC ISCHEMIC ENCEPHALOPATHY
S/P TRACHEOSTOMY WITH K/C/O SEIZURE DISORDER
Case History and Clinical Findings:
PATIENT IS IN VEGETATIVE STATE FOR PAST 8-9 MONTHS AND TRACHEOSTOMY WS DONE. IN 2019, HE HAD ONCE C/O LEFT UPPER QUADRANT ABDOMINAL PAIN WHEN THE PAINI NTENSIFIED HE WAS TAKEN RO LOCAL HOSPITAL, GOT ADMITTED FOR 2 DAYS AND DISCHARGED. NO SUCH INCIDENT AFTER DISCHARGE 9 MONTHS AGO, ONE LATE NIGHT AT AROUND 10PM, HIS FRIEND DROPPED HIM 800 METRES AWAY FROM HOME NEAR A LAMP PEAT AFTER HEAVY DRINKING WITH HIS FRIENDS 5 MINUTES LATER HIS FRIEND SAW PATIENT IS HUGGING THE LAMP PEAT TIGHTLY. HE WAS NOT REPLYING WHEN HE CALLED THE PATIENT. SO WHEN HE TRIED TO TOUCH THE PATIENT, HE GOT AN ELECTRIC SHOCK. REALIZING PATIENT HAD BEEN ELECTROCUTED HE CALLED HIS ANOTHER FRIENDS AND THEY TOOK HIM TO THE HOSPITAL. HE WAS UNCOSCIOUS UPON REACHING THE HOSPITAL CPR WAS GIVEN AND VENTILATION DONE. DOCTOR SAID THAT HE IS IN VEGETATIVE STATE AND REFERRED HIM TO ANOTHER HOSPITAL. THERE IN THAT HOSPITAL TRACHEOSTOMY WAS DONE AND HE STAYED IN THE HOSPITAL FOR 45 DAYS. BY THAT TIME HE WAS ABLE TO MOVE HIS FINGERS SLIGHTLY. DOCTOR SAID NOTHING MORE CAN BE DONE AND GOT DISCHARGED. HE WAS ADMITTED TO ANOTHER HOSPITAL, WHERE HE STAYED TO DATE. IN THE PAST 9 MONTHS TILL DATE, SLOWLY HE IS ABLE TO BLINK HIS EYES, MAKE EYE CONTACT, GRIP SOMEONE'S FINGER. HE IS TRYING TO LIFT HIS HEAD. FOR THE PAST 2-3 MONTHS HE IS ABLE TO SIP WATER WHEN FED VIA SPOON. STILL BEING FED VIA RYLES TUBE
PAST HISTORY:N/K/C/O DM, HTN, TB, BA, CAD
TRACHEOSTOMY DONE 9 MONTHS AGO
PERSONAL HISTORY; REGULAR ALCOHOLIC
GENERAL PHYSICAL EXAMINATION:
AT ADMISSION
NO SIGNS OF PALLOR, ICTERUS, CLUBBING, CYANOSIS, GENERALISED
LYMPHADENOPATHY
BP 110/80MMHG
PR 110BPM
RR 22CPM
TEMP AFEBRILE
SPO2 99% ON RA
SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM:
S1 AND S2 HEARD. NO MURMURS
RESPIRATORY SYSTEM: BAE PRESENT, CLEAR
CENTRAL NERVOUS SYSTEM:
GCS:E3V2M4
PUPILS REACTING
CORNEAL AND CONJUCTIVAL REFLEX PRESENT
TONE; RIGHT LEFT
UPPER LIMB STIFF STIFF
LOWER LIMB NORMAL NORMAL
POWER: UNABLE TO ELICIT
REFLEXES: RIGHT LEFT
BICEPS 2+ 2+
TRICEPS. 1+ 1+
SUPINATOR. 1+ 1+
KNEE 2+ 2+
ANKLE 1+ 1+
PLANTAR FLEXOR FLEXOR
COURSE IN THE HOSPITAL:
DAY1
EXAMINATION OF CNS
GCS:E3V2M4
PUPILS REACTING
CORNEAL AND CONJUCTIVAL REFLEX PRESENT
TONE; RIGHT LEFT
UPPER LIMB STIFF STIFF
LOWER LIMB NORMAL NORMAL
POWER: UNABLE TO ELICIT
REFLEXES: RIGHT LEFT
BICEPS 2+ 2+
TRICEPS 1+ 1+
SUPINATOR 1+ 1+
KNEE 2+ 2+
ANKLE 1+ 1+
PLANTAR FLEXOR FLEXOR
DAY2
THE CALORIE REQUIREMENT IS CALCULATED BASED ON THE HARRIS BENEDICT EQUATION FOR BASAL ENERGY EXPENDITURE.
1272.9 CALORIES
32-40GM PROTEIN
42.4 GM OF FAT
158.2 GMS OF CARBOHYDRATES
DAY 3
ENT REFERRAL WAS DONE ON 15/03/2023 AND ADVISED X RAY AP, LATERAL VIEW OF NECK, CHEST X RAY, FLP. AFTER FLEXIBLE LARYNGOSCOPY PROCEDURE,
DAY 4
ENT SURGEON ADVISED TRACHEOSTOMY TUBE CHANGE - METALLIC NO 30 AND DECANNULATION IS NOT ADVISABLE BUT CAN BE DONE ON ATTENDER'S REQUEST WITH
HIGH RISK ASPIRATION PNEUMONITIS.
DAY 5;REFERRAL TO OMFS DONE IN VIEW OF PREVENTION OF TONGUE BITE OMFS ADVISED FOR ANTI BITE DEVICES (MOUTH GUARDS) TO PREVENT TONGUE BITE
Investigation
ECG
X RAY NECK AP AND LATERAL VIEW : TRACHEOSTOMY TUBE NOTED AT C3, C4, C5 VERTEBRAE LEVELS. MILD SOFT TISSUE THICKENING NOTED AT C3, C4, C5 VERTEBRAE
LEVELS.
CHEST X RAY : NO RADIOGRAPHICAL ABNORMALITY DETECTED
Treatment Given(Enter only Generic Name)
1. RYLES TUBE FEEDING LUKE WARM WATER = 4 SCOOPS OF ENSURE 3 TIMES/DAY
100 ML OF WATER 3RD HOURLY
2. TAB. RANITIDINE 150MG PO/OD
3. TAB. CALCIUM CITRATE, VIT-K2 AND CALCITRIOL PO/OD
4. TAB. LEVETIRACETAM 500 MG PO/BD
5. SUCTIONING EVERY 2ND HOURLY
6. VITALS MONITORING
Advice at Discharge
1. RYLES TUBE FEEDING LUKE WARM WATER = 4 SCOOPS OF ENSURE 3 TIMES/DAY
100 ML OF WATER 3RD HOURLY
2. TAB. RANITIDINE 150MG PO/OD
3. TAB. CALCIUM CITRATE, VIT-K2 AND CALCITRIOL PO/OD
4. TAB. LEVETIRACETAM 500 MG PO/BD
5. SUCTIONING EVERY 2ND HOURLY
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