Fever projr unclassified
CASE :
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
COURSE IN HOSPITAL
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
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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