27 M with history of Electrocution
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CASE
CHIEF COMPLAINTS:-
This is a case of a 27 year old male, resident of chattisgarh who was brought to seek advise for removal of tracheostomy tube.
HISTORY OF PRESENTING ILLNESS : -
Pt is a 27 yrs old male, who after doing an ITI course was looking for a job.
8 months ago, one late night at around 10 pm, his friend dropped him some 800mts away from home near a lamppost after heavy drinking with his friends. 5 mins later while passing from that same area, his friend saw the pt is hugging the lamppost tightly. He was not replying when he called the pt. So, when he tried to touch the pt, he too got an electric shock. Realizing pt had been electrocuted he called his other friends and they took him to the hospital. His friend had reported while taking pt to the hospital he was unconscious. Upon reaching the hospital CPR was given and kept in ventilation. After 18 hours, the pt's eyelids were showing slight movement. Dr said he is in a vegetative state and referred him to another hospital.
Their tracheostomy was done and he stayed in that hospital for 45 days. By that time, he was able to move his fingers slightly. Dr. said nothing more can be done and he got discharged.
He was admitted to another hospital, where he is staying to date.
In the past 5-6 months till date, slowly he is able to blink his eyes, make eye contact, grip someone's finger, open his mouth, can also lift his hands a little bit. He is trying to speak and 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.
Pt appears malnourished.
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.
Psychosocial component:
Pt as a child was very fun-loving. Used to roam around with friends and play around.
When in class 6, lost his father who was a heavy drinker and a daily wage laborer. His father's drinking habit would often lead to quarrels with his mom.
After their father's death (a few years after retirement), their mom became the sole earner (contract laborer). As per the elder son she never made them feel like they were short of money. Pt's brother reported though they were small, their father's death didn't have much on any of them.
Pt's brother thinks Mom used to like and pamper her younger son(pt) more than him.
In class 10-11, pt's elder brother went away to study elsewhere. Since then, there were only small interactions between the two brothers. Pt started mixing with friends some of whom were heavy drinkers. He often started coming home late at night after heavy drinking (friends reported he used to get drunk easily). Because of this, his mom used to scold him and used to tell him to look for a job, which often resulted in small quarrels. He not being a very good student couldn't land himself a job. His mom made him give some job interviews (e.g police) and even made him get some with her contacts, but he won't go, because he was not interested.
His friends reported he while drinking would often repent about not being able to get a job and support his family. He considered himself to be a family burden, which would often lead to more drinking. They claimed he was in depression.
His family does not know how he got electrocuted but also suspects him of trying to commit suicide by touching a live wire, apart from it being accidental.
PERSONAL HISTORY:-
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 : -
Pt started drinking locally made alcohol (mostly with friends outside, quantity unknown) at 16-17 yrs of age. Since his mom won't give him money to drink, his friends use to give him money.
Used to chew tobacco (quantity unknown) since the age of 16-17 yrs.
Smoked cigarettes (no. unknown) occasionally with friends.
FAMILY HISTORY:-
Father passed away and he was a heavy drinker
Mother :- Not a known car of HTM, DM.
Mild knee pain in both lower limbs
while climbing stairs
Elder Brother :- Healthy
Sister :- Healthy
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 :-
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- Normal Temperature
Pulse rate- 98 bpm
Respiratory rate- 18 cpm
BP - 110/80 mm Hg
SpO² - 98%
SYSTEMIC EXAMINATION:-
CENTRAL NERVOUS SYSTEM-
● GCS :- 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 fists 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 :-
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