25yr old male with traumatic brain injury secondary to RTA with intraventricular hemorrhage
25 YEAR OLD MALE PATIENT WITH TRAUMATIC BRAIN INJURY SECONDARY TO RTA WITH INTRAVENTRICULAR HEMORRHAGE
26th March 2023
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Dr. M. Prathyusha ( Intern )
Roll no : 96
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.
CASE :
25 YEAR OLD MALE PATIENT BROUGHT TO CASUALTY WITH H/O FALL FROM BIKE UNDER ALCOHOL INFLUENCE AT 9:30 PM NEAR HALIYA,NALGONDA ON 20/03/23.
AND THEN TAKEN TO HOSPITAL FOR FURTHER MANAGEMENT.PATIENT IS INVESTIGATED AND DIAGNOSED TO HAVE RTA , TRAUMATIC BRAIN INJURY,WITH INTRAVENTRICULAR HEMORRHAGE WITH FRONTAL BONE FRACTURE WITH ASPIRATION PNEUMONIA AND RIGHT FRONTAL LACERATION SOFT TISSUE REPAIR WITH DEBRIDEMENT WAS DONE ON 20/3/23.
PATIENT WAS INTUBATED ON 20/3/23 I/V/O POOR GCS WITH FIO2: 100% MODE: VC WITH ANTIEPILEPTIC MEDICATIONS.
PATIENT IS SEDATED AND PARALYSED
HR: 101/MIN
BP: 130/80 MMHG
CVS: S1S2+
R/S: BAE+, B/L CREPTS +
PUPILS: SLUGGISH RTL, ASYMMETRICAL SPO2: 98% WITH FIO2: 100%
TEMP: Afebrile
FOCAL SEIZURES+ (ON & OFF)
MYOCLONIC JERKS (ON & OFF)
MENTIONED COMPLAINTS, PATIENT IS EXAMINED AND ALL NECESSARY INVESTIGATIONS WERE DONE.
ON EXAMINATION: (20/03/2023) PATIENT IS NOT RESPONDING TO ORAL COMMANDS BUT
SPONTANEOUS MOVEMENTS ARE PRESENT
2 D ECHO SHOWN NORMAL STUDY
GCS: E1V1MS
CT BRAIN WAS DONE AND S/O INTRA VENTRICULAR HEMORRHAGE .
DURING THE HOSPITAL STAY PATIENT HAD 1 SEIZURE EPISODE ON 20/03/23 ( 12:45PM) AND PATIENT MANAGED FOR 2 DAYS
ET CULTURE SHOWED KLEBSIELLA ON 21/3/23 WITH INTERMEDIATE SENSITIVITY TO AZTREONAM AND EXTUBATED ON 21/03/2023.
AFTER EXTUBATION , PATIENT IS STABLE FOR 2 DAYS AND THEN SHIFTED TO ROOM AND THEN HE HAD H/O INSOMNIA, H/O RESTLESSNESS OVER NIGHT, PATIENT HAD SUDDEN CARDIAC ARREST AT 7.30 AM (25/03/2023) AND AGAIN PATIENT WAS REINTUBATED AT 7.30 AM ON 25/03/2023. AFTER 2 CYCLES OF CPR PATIENT REVIVED, SHIFTED TO ICU AND LATER CONNECTED TO MECHANICAL VENTILATOR WITH FIO2: 100% PATIENT HAD FOCAL SEIZURES (ON & OFF),S/O HIE(HYPOXIC ISCHEMIC ENCEPHALOPATHY) WITH STRESS MYOCARDITIS, ANTIEPILEPTIC MEDICATIONS GIVEN, INJ.MIDAZ INFUSION, IONOTROPE STARTED.
PATIENT SHIFTED HERE FOR FURTHER MANAGEMENT.
TREATMENT GIVEN IN OTHER HOSPITAL:-
1) INJ.AZTREONAM 1 GM/IV/ 1-0-1 (DAY-1)
2) INJ.CLINDAMYCIN 600 MG /IV/ 1-1-1(DAY6
3) INJ.PAN 40 MG /IV/ 1-0-0
4) INJ.LEVERA 1GM /IV/ 1-0-1
5) INJ.LACOSAM 200 MG /IV/ 1-0-1
6) INJ.NOOTROPIL 800 MG /IV/ 1-1-1
7) INJ.CITICOLINE 500 MG /IV/ 1-0-1
8) INJ.THIAMINE 200 MG /IV/ 1-0-1
9) INJ.OPTINEURON 1 AMP /IV/ 0-1-0
10) INJ.MEGANEURON FORTE 1000 MCG /IV/ 0-1-0 (D4/D5)
11) TAB.TOCOMORE /RT/ 1-0-1
12) TAB.CHYMEROL FORTE /RT/1-1-1 13) TAB.CLOBA 10 MG /RT/ HS (9PM)
14) TAB.CAVIT XT /RT/ 0-1-0
15) TAB.LIBRIUM 10 MG /RT/1-1-1
16) NEB WITH DUOLIN (1-1-1) AND BUDECORT (1-0-1)
17) SYP.GLYCEROL 30 ML WITH WATER /RT/ 1-1-1
18)INJ.NORAD 8 ML/HR IV INFUSION
PAST HISTORY :
NO H/O DM,HTN,EPILEPSY,TB, THYROID,CAD,CVA, ASTHMA
PERSONAL HISTORY:
APPETITE-NORMAL
DIET - MIXED
BOWEL - NORMAL
BLADDER- NORMAL(AT PRESENT ON FOLEYS CATHETER)
ADDICTIONS- ALCOHOL CONSUMPTION
LAST BINGE ON THE DAY OF RTA(20/3/23)
FAMILY HISTORY:
NO SIGNIFICANT FAMILY HISTORY
GENERAL EXAMINATION:-
PT IS C,C,C
NO ICTERUS , CYANOSIS, CLUBBING, LYMPHADENOPATHY , PEDAL EDEMA.
VITALS -
Temp -98.4F
PR - 126bpm
BP - 120/80mmhg
RR - 26cpm
SpO2 - 100% on FIO2 100%
SYSTEMIC EXAMINATION :
PER ABDOMEN :
INSPECTION :
UMBILICUS IS CENTRAL AND INVERTED
ALL QUADRANTS ARE MOVING EQUALLY WITH RESPIRATION
NO SINUSES , ENGORGED VEINS, VISIBLE PULSATIONS .
HERNIAL ORIFICES ARE FREE
PALPATION :
ABDOMEN IS SOFT IN CONSISTENCY.
NO ORGANOMEGALY.
LIVER AND SPLEEN - NOT PALPABLE
PERCUSSION : TYMPANIC NOTE HEARD OVER THE ABDOMEN.
AUSCULTATION:BOWEL SOUNDS ARE HEARD.
CARDIOVASCULAR SYSTEM:
INSPECTION:
SHAPE OF CHEST IS ELLIPTICAL.
NO RAISED JVP
NO VISIBLE PULSATIONS, SCARS , SINUSES , ENGORGED VEINS
PALPATION:
APEX BEAT - FELT AT LEFT 5TH INTERCOSTAL SPACE
NO THRILLS AND PARASTERNAL HEAVES
AUSCULTATION :
S1 AND S2 HEARD.
RESPIRATORY SYSTEM:
BAE PRESENT, NVBS HEARD
CENTRAL NERVOUS SYSTEM:-
PATIENT IS ON MECHANICAL VENTILATOR ON ACMV -VC MODE
GCS- E1VtM1
RR- 14 CPM
FIO2- 100%ON ARRIVAL NOW REDUCED TO60%
PEEP -5 CM OF H2O
Tv- 400ml
Tinsp-1.4
PATIENT IS SEDATED AND PARALYSED.
INVESTIGATIONS:-
CBP:
Hb -17.0 gm/dl
TLC - 13000cells/ cumm
RBC - 5.81 million
PLT -3.62 lakh
PCV-50.6
PT- 16 SEC
APTT- 33SEC
INR-1.11
BT- 2min30sec
CT- 4 MIN 30 SEC
BGT- B+VE
RBS- 141
CUE :
Albumin- 4+
Sugars - nil
RFT:
urea - 22mg/dl
Creatinine - 0.7mg/dl
Na - 142mEq/L
K - 3.8mEqL
Cl - 101mEq/L
calcium-9.9
Uric acid -2.0mg/dl
LFT :
TB- 1.43mg/dl
DB- 0.51 mg/dl
SGPT -71 IU/L
SGOT - 126 IU/L
ALP - 146IU/L
TP - 8.2gm/dl
albumin - 4.3gm/dl
A/G ratio- 1.12
CHEST XRAY :-
ECG-
On25/3/23
PROVISIONAL DIAGNOSIS:-
RTA , TRAUMATIC BRAIN INJURY(SEVERE),WITH INTRAVENTRICULAR HEMORRHAGE WITH FRONTAL BONE FRACTURE WITH ASPIRATION PNEUMONIA (RESOLVED)AND
s/p -RIGHT FRONTAL LACERATION SOFT TISSUE REPAIR WITH DEBRIDEMENT WAS DONE ON 20/3/23.
FOCAL SEIZURES SECONDARY TO IVH
SUDDEN CARDIAC ARREST-? HIE(HYPOXIC ISCHEMIC ENCEPHALOPATHY)
S/p POST CPR STATUS
?SEVERE CARDIOMYOPATHY( TAKOTSUBO CARDIOMYOPATHY)
SEVERE LV DYSFUNCTION -LVEF(15-20%)
TREATMENT -
1.RT FEEDS - 100ml water 2nd HRLY
200ml milk + 2 scoops protein powder 4th hrly.
2. INJ.NORADRENALINE (2AMP+46 ML NS)
3.INJ.ATRACURIUM 1 amp (diluted)+ 46 ML NS @5ML/HR
4.INJ. MIDAZOLAM@5ML/HR
5.INJ.3%NS @20ML/HR
6.INJ. LEVITARACETAM 1GM IV BD
7. INJ.LACOSAMIDE 200mg IV BD
8.EYE CARE,FREQUENT POSITION CHANGING,AIR BEDDING
4/4/23
ICU BED NO.1
S
FEVER SPIKES -PRESENT
At 11am 103F
At 4pm 105 F
At 1am 101.3F
O
Patient
GCS-E4V1M4
BP- 110/70 mm hg
PR- 102 bpm
RR- 36CPM
FIO2- 21% with CPAP VC
PEEP -5 CM OF H2O
GRBS-99mg/dl
Temp- 100.6F
SpO2 - 99% with CPAP VC
I/O- 5600/4050 ml
CVS- S1,S2 heard, no murmurs
RS- BAE (+), Grunting (+) B/L diffuse
CNS :BRAIN STEM REFLEXES INTACT
P/A-soft,no organomegaly
A
RTA , TRAUMATIC BRAIN INJURY(20/3/23) WITH INTRAVENTRICULAR HEMORRHAGE(RESOLVED) WITH ASPIRATION PNEUMONIA(RESOLVED) FRONTAL BONE FRACTURE s/p -RIGHT FRONTAL LACERATION SOFT TISSUE REPAIR WITH DEBRIDEMENT WAS DONE ON 21/3/23.HFMEF (EF-50%)
SUDDEN CARDIAC ARREST-? HIE ON MECHANICAL VENTILATION DAY-5 (25/3/23) POST CPR STATUS(2CYCLES) ON (25/3/23 ) ANTERIOR WALL MI (EVOLVED)
S/P TRACHEOSTOMY (29/3/23)
RECURRENT HYPOKALEMIA SECONDARY TO RENAL LOSS WITH GRADE 2 BED SORE (DAY1) ?SEPSIS with LEFT MIDDLE LOBE CONSOLIDATION
P
1.RT FEEDS - 200ml water 2nd HRLY
200ml milk + 2 scoops protein powder 4th HRLY
2. IV Fluids NS 125ml/hr
3. INJ. SODIUM VALPROATE 1gm IV/BD
4.INJ. NEOMOL 1GM IV/SOS IF TEMP > 101F
5.INJ.CLEXANE 4Omg SC/BD( DAY 7)
6.T PCM 650 mg RT/SOS
7.Vitals monitoring 2nd hrly
8.Temp monitoring 2nd hrly
9. Strict input,output charting
10.Eye care frequent position change ,air bed , stockings
11. Neosporin powder and bedsore dressing
12. Hourly suctioning
13.Neb.with Ipravent 4th hourly
14.T.CITICHOLINE 500mg RT/BD
15.T.DONEP-M RT/BD
16.T.AMANTAX 100 mg RT/BD
17.T.BROMOCRIPINE 2.5mg RT/BD
18.INJ. GLYCOPYROLATE 1mg IV/SOS
19.Syp .POTKLOR 15ml RT/TID
20. INJ .PIPTAZ 4.5mg IV/TID( DAY 3)
21.Physiotherapy -chest and B/L upper and lower limbs
5/4/23
ICU BED NO.1
S
FEVER SPIKES -PRESENT
At 11am -101.3F
O
Patient
GCS-E4V1M4
BP- 130/90 mm hg
PR- 82 bpm
RR- 26CPM
GRBS-110mg/dl
Temp- 100.6F
SpO2 - 93% ON RA
I/O- 5000/3900 ml
CVS- S1,S2 heard, no murmurs
RS- BAE (+), NVBS
CNS :BRAIN STEM REFLEXES INTACT
P/A-soft,no organomegaly
A
RTA , TRAUMATIC BRAIN INJURY(20/3/23) WITH INTRAVENTRICULAR HEMORRHAGE(RESOLVED) WITH ASPIRATION PNEUMONIA(RESOLVED) FRONTAL BONE FRACTURE s/p -RIGHT FRONTAL LACERATION SOFT TISSUE REPAIR WITH DEBRIDEMENT WAS DONE ON 21/3/23.HFMEF (EF-50%)
SUDDEN CARDIAC ARREST-? HIE ON MECHANICAL VENTILATION DAY-5 (25/3/23) POST CPR STATUS(2CYCLES) ON (25/3/23 ) ANTERIOR WALL MI (EVOLVED)
S/P TRACHEOSTOMY (29/3/23)
RECURRENT HYPOKALEMIA WITH GRADE 2 BED SORE (DAY2) ?SEPSIS with LEFT MIDDLE LOBE CONSOLIDATION ? ventilator associated pneumonia
P
1.RT FEEDS - 200ml water 2nd HRLY
200ml milk + 2 scoops protein powder 4th hrly.
2. IV Fluids NS 125ml/hr
3. INJ. SODIUM VALPROATE 1gm IV/BD
4.INJ. NEOMOL 1GM IV/SOS IF TEMP > 101F
5.INJ.CLEXANE 4Omg SC/BD( DAY 8)
6.T PCM 650 mg RT/SOS
7.Vitals monitoring 2nd hrly
8.Temp monitoring 2nd hrly
9. Strict input,output charting
10.Eye care frequent position change ,air bed , stockings
11. Neosporin powder and bedsore dressing
12. Hourly suctioning
13.Neb.with Ipravent 4th hourly
14.T.CITICHOLINE 500mg RT/BD
15.T.DONEP-M RT/BD
16.T.AMANTAX 100 mg RT/BD
17.T.BROMOCRIPINE 2.5mg RT/BD
18.INJ. GLYCOPYROLATE 1mg IV/SOS
19.Syp.POTKLOR 15ml RT/TID
20. INJ .PIPTAZ 4.5mg IV/TID( DAY 4)
21.Physiotherapy -chest and B/L upper and lower limbs
6/4/23
ICU BED NO.1
S
FEVER SPIKES -PRESENT
At 11pm 101
O
Patient
GCS-E4V1M4
BP- 130/70 mm hg
PR- 102 bpm
RR- 26CPM
GRBS-103 mg/dl
Temp- 99.8F
SpO2 - 97% ON RA
I/O- 4500/4600 ml
CVS- S1,S2 heard, no murmurs
RS- BAE (+), NVBS
CNS :BRAIN STEM REFLEXES INTACT
P/A-soft,no organomegaly
A
RTA , TRAUMATIC BRAIN INJURY(20/3/23) WITH INTRAVENTRICULAR HEMORRHAGE(RESOLVED) WITH ASPIRATION PNEUMONIA(RESOLVED) FRONTAL BONE FRACTURE s/p -RIGHT FRONTAL LACERATION SOFT TISSUE REPAIR WITH DEBRIDEMENT WAS DONE ON 21/3/23.HFMEF (EF-50%)
SUDDEN CARDIAC ARREST-? HIE ON MECHANICAL VENTILATION DAY-5 (25/3/23) POST CPR STATUS(2CYCLES) ON (25/3/23 ) ANTERIOR WALL MI (EVOLVED)
S/P TRACHEOSTOMY (29/3/23)
RECURRENT HYPOKALEMIA WITH GRADE 2 BED SORE (DAY2) ?SEPSIS with LEFT MIDDLE LOBE CONSOLIDATION ? ventilator associated pneumonia
P
1.RT FEEDS - 200ml water 2nd HRLY
200ml milk + 2 scoops protein powder 4th hrly.
2. IV Fluids NS 125ml/hr
3. INJ. SODIUM VALPROATE 1gm IV/BD
4.INJ. NEOMOL 1GM IV/SOS IF TEMP > 101F
5.INJ.CLEXANE 4Omg SC/BD( DAY 8)
6.T PCM 650 mg RT/SOS
7.Vitals monitoring 2nd hrly
8.Temp monitoring 2nd hrly
9. Strict input,output charting
10.Eye care frequent position change ,air bed , stockings
11. Neosporin powder and bedsore dressing
12. Hourly suctioning
13.Neb.with IPRAVENT 4th hourly
14.T.CITICHOLINE 500mg RT/BD
15.T.DONEP-M RT/BD
16.T.AMANTAX 100 mg RT/BD
17.T.BROMOCRIPINE 2.5mg RT/BD
18.INJ. GLYCOPYROLATE 1mg IV/SOS
19.Syp .POTKLOR 15ml RT/TID
20. INJ .PIPTAZ 4.5mg IV/TID( DAY 4)
21.Physiotherapy -chest and B/L upper and lower limbs
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