1801006051 CASE PRESENTATION

LONG CASE 

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 

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SHORT CASE

CHIEF COMPLAINTS: 

Patient was brought to casuality with complaints of neck pain since 3 days, vomitings and headache since 1day.. 

HISTORY OF PRESENTING ILLNESS:

Pt was asymptomatic 3 days back then she developed neck pain. 

Vomitings since 1 day with 4 to 5 episodes per day, non bilious type.. 

Headache  with facial puffiness since 1 day which is of frontal type. 

PAST HISTORY:

She was bought to this hospital 1 month back for fever, sore throat, dry cough, reduced urine output, shortness of breath, pedal oedema extended till knees and  hyper pigmented macules seen over the fore head and legs , diagnosed with SLE with anti ds DNA++ , anti histone antibodies positive..

N/k/c/o Diabetes, TB or asthma., CAD, epilepsy 

Addictions : none 

FAMILY HISTORY :  no significant family history 

Surgical history: No surgeries done in past. 

TREATMENT HISTORY : treated 1 month back with

INJ AUGMENTIN 

INJ LASIX 

BUDECORT 

BETADINE GARGLING

TAB AZITHROMYCIN

PERSONAL HISTORY:

Diet: mixed

Appetite : decreased

Sleep : inadequate

Bowel movements : regular 

GENERAL EXAMINATION : patient was examined after taking consent from the attenders

Pt is conscious cooperative and coherent 

Pallor - present 

Icterus- absent

Cyanosis- absent

Clubbing- absent

Koilonychia - absent

Lymphadenopathy - absent

Edema - absent 

SYSTEMIC EXAMINATION : 

CVS : 

No thrills, no parasternal heave, 

S1, S2 +, no murmurs

RESPIRATORY SYSTEM : BAE + 

Trachea is central in position, no dyspnoea, no wheeze, vesicular breath sounds heard

ABDOMEN EXAMINATION : 

Non tender , bowel sounds heard 

CNS : No focal neurological deficit 

Oriented to person,time and place 

Speech - normal

 Signs of meningeal irritation - not present

INVESTIGATIONS

Serum electrolytes: Normal 

Serum Creatinine normal 

Blood sugar- normal 

"Blood urea is elevated":64 mg/dl(12 to 42 mg/dl)

LFT:

Elevated alkaline phosphate-123 IU/L (42-98 IU/L)

ABG : 

HEMOGRAM:

Hemoglobin isReduced-10.2gm/dl (12-15 gm/dl) 

Lymphocytes are reduced-08% (20-40%) 

Neutrophils-82% (40-80%) 

-Normocytic normochromic anemia with neutrophilic leukocytosis..

MCHC is reduced-30.8%(31.5 - 34.5%) 

RDW-CV is raised - 17.8%( 11.6 - 14%) 

Rbc count is reduced-3.47millions/cumm(3.8-4.8)

PROVISIONAL DIAGNOSIS: 

SLE 

TREATMENT : 

Tab paracetamol 500mg PO/TID 

Tab warfarin 5mg PO/BD 

Tab HCQ 200mg PO/OD 

Tab azathioprine 50mg PO/BD 

Tab prednisolone PO/BD 

Inject zofer 4mg iv/BD 

syrup sucralfate 15ml PO/BD 

Monitor vitals