1801006088- LONG CASE

1801006088- LONG CASE

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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.

27 yr old male patient came to our hospital to seek medical advise for removal of tracheostomy tube. 

 HISTORY OF PRESENTING ILLNESS  : -

PSYCHOLOGICAL HISTORY:-

When young, patient was a good kid and enthusiastic.

When he was 6 yrs old he lost his father (who was a heavy drinker and was a daily wage labourer ).

After this event his mother become the sole bread winner of the family.

His brother left the house for further education,  during this time the patient started to make friends then he got addicted to alcohol.

He wasn't great with studies and used to roam jobless, he started coming to home later night.

He on his mother's request completed graduation and then started to look for a job, to support the family.

PAST HISTORY: -

● He had several episodes of seizures 3 months later following the electric shock. 

● Not a known case of HTN, DM , Asthma , TB 

● Tracheostomy was done.

FAMILY HISTORY:- 

● Father passed away and he was a heavy drinker

● Mother :- Not a known case of HTN, DM.

                     Mild knee pain in both lower limbs

.                    while climbing stairs

● Elder Brother :-  Healthy

● Sister :- Healthy

PERSONAL HISTORY:- 

Height :- 5'6 --> 164.67 cms

Weight :- 40 kg approx.

Appetite :- decreased 

Diet :- feeding done through Ryle's Tube

           Breakfast :- Protein powder shake

           Afternoon:- Rice and dal with water

           Snacks:- Biscuits and milk 

           Dinner :-  Rice and dal with water

Sleep -  Adequate

Bowel and Bladder movements-  regular 

ADDICTIONS : -

After his brother left for his further studies, patient got new friends and new habits with it at a young age.

● Alcohol - he started when he was around 16-17 yrs old.

                     Quantity unknown.

● Smoking - occasionally with friends.

● Tobacco chewing - Regular. Quantity is unknown.

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. CALCITRIOL And Vit K PO/OD (after lunch)

GENERAL PHYSICAL EXAMINATION  :- 

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

VITALS:-

       Temperature- 2 pm -> 98.4°F

                                 4 pm -> 98.6°F

                                 6 pm -> 98.2°F

       Pulse rate- 2 pm -> 102 bpm

                           4 pm -> 102 bpm

                           6 pm -> 100 bpm

      Respiratory rate- 2 pm -> 26 cpm

                                      4 pm -> 26 cpm

                                      6 pm -> 18 cpm

      BP - 2 pm, 4 pm, 6 pm -> 110/80 mm Hg    

      SpO² - 2 pm , 4 pm -> 98% 

                  6 pm -> 100%

                                                  

 

SYSTEMIC EXAMINATION:-

   

CENTRAL NERVOUS SYSTEM-

● GLASGOW COMA SCALE:- E4 V2 M4 At the time of examination

  

● Higher mental functions -

       vegetative state,  disoriented

       Speech, memory and intellect couldn't 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 :-  couldn't be performed as                                                                 patient kept his fist clenched.

 

● Cranial Nerve examination:-

          pupillary reflex :Direct and indirect light reflex seen

         Trigeminal:

                   Corneal and conjunctival present

                 

        Gag reflex is present 

        Tongue moments present

 

● Motor System :- 

                             Right                                    Left

                     UL               LL                     UL             LL

Bulk        wasted        wasted            wasted      wasted

Tone    hypertonia    normal       hypertonia    normal

Power :- Not able to elicit            not able to elicit

Reflexes :- 

 Biceps, Triceps, Supinator reflexes are absent 

 Knee reflex positive in both limbs

 Ankle reflex positive in both limbs  

 Plantar reflex positive in both limbs

● Sensory System :- couldn't be elicited

● Myoclonic jerks are seen regularly

                                                                   

● Gait:- couldn't be elicited

CARDIOVASCULAR SYSTEM :- 

S1 and S2 are heard.

No murmurs are heard

Apex beat felt at 5th ICS

RESPIRATORY SYSTEM :-  

 B/L basal crepitations are heard

ABDOMINAL SYSTEM:-

 Soft and non tender 

ENT EXAMINATION:-

Nose :- 

   External frame work is normal.

   DNS to left is noticed.

   Ryle's tube in the right nasal cavity. 

Oral cavity and Oropharynx:

   Couldnot be examined as patient is not co-operative.

Trachea:-

  Central

  Tracheostomy tube was placed 

                                                        

INVESTIGATIONS:- 

X- RAY of neck :-

                            

Chest X Ray :-

                            

MRI:-

PROVISIONAL DIAGNOSIS :-

Hypoxic Ischemic Brain Injury Post CPR state 

TREATMENT PLAN:- 

After Neurology consultation , The Neurologist  suggested for Family Counselling and Palliative Therapy.