We have a patient on our inpatient service who came in yesterday afternoon...very interesting so far...wanted to see what you guys think this is...
HPI: (as reported by his father) 20 year old WM, previously healthy, was at work when he fell down some stage steps. The patient's co-workers did not see the fall but state that he started acting strangely approximately 30 minutes after the fall, was clenching his hands and reaching for things but falling short of grabbing them. The patient also complained of dizziness and nausea. MAST ambulance was called. Upon arrival, the patient was combative and unresponsive to verbal commands. Pt was then sedated and had to be intubated in the ED in order to get CT.
The parents report him being a normal, healthy 20 year old with no previous episodes like this. They also state that he was very normal the night before, had dinner together, and watched a movie at home.
PMH: none
Medications: none
FH: non-contributory
SOCIAL HISTORY: No drugs, no alcohol, no tobacco. Electrician. Lives with his parents.
GENERAL: A 20-year-old white male with no obvious signs of trauma who is intubated, and on vent.
VITAL SIGNS: Tmax 102.1, Tc 99.2 Blood pressure 104/38, pulse 60, respirations 10, saturating 100% on 40% oxygen.
HEENT: Normocephalic atraumatic. The patient's pupils are equal, round and reactive to light and accommodation, although sluggish. No obvious signs of trauma.
CHEST: Lungs clear to auscultation bilaterally.
CARDIOVASCULAR: S1 and S2, no murmurs.
ABDOMEN: Soft with a large scar in his abdomen from surgery as a child. No masses are noted. Bowel sounds are positive.
EXTREMITIES: No edema, 2+ pulses, decreased reflexes bilaterally in lower extremities.
NEUROLOGIC: The patient is intubated. Pupils are equal, round and reactive to light and accommodation. No Babinski is noted. The patient is moving all extremities.
LABORATORY/PERTINENT DATA: CT and MRI of the head are negative
INR 1.29. CBC: White blood cell count 16.5, H&H 14.2 and 41 with platelets of 197. BMP showed a sodium of 140, potassium 3.6, chloride 101, CO2 of 25, BUN of 10 and creatinine 0.8. Blood glucose 121.
UA and UDS were both negative
Currently, the patient is still intubated and sedated with propofol. Trial in decreasing propofol was done today in which the patient failed and became combative. The patient is currently on prophylactic phenytoin. ???????????
HPI: (as reported by his father) 20 year old WM, previously healthy, was at work when he fell down some stage steps. The patient's co-workers did not see the fall but state that he started acting strangely approximately 30 minutes after the fall, was clenching his hands and reaching for things but falling short of grabbing them. The patient also complained of dizziness and nausea. MAST ambulance was called. Upon arrival, the patient was combative and unresponsive to verbal commands. Pt was then sedated and had to be intubated in the ED in order to get CT.
The parents report him being a normal, healthy 20 year old with no previous episodes like this. They also state that he was very normal the night before, had dinner together, and watched a movie at home.
PMH: none
Medications: none
FH: non-contributory
SOCIAL HISTORY: No drugs, no alcohol, no tobacco. Electrician. Lives with his parents.
GENERAL: A 20-year-old white male with no obvious signs of trauma who is intubated, and on vent.
VITAL SIGNS: Tmax 102.1, Tc 99.2 Blood pressure 104/38, pulse 60, respirations 10, saturating 100% on 40% oxygen.
HEENT: Normocephalic atraumatic. The patient's pupils are equal, round and reactive to light and accommodation, although sluggish. No obvious signs of trauma.
CHEST: Lungs clear to auscultation bilaterally.
CARDIOVASCULAR: S1 and S2, no murmurs.
ABDOMEN: Soft with a large scar in his abdomen from surgery as a child. No masses are noted. Bowel sounds are positive.
EXTREMITIES: No edema, 2+ pulses, decreased reflexes bilaterally in lower extremities.
NEUROLOGIC: The patient is intubated. Pupils are equal, round and reactive to light and accommodation. No Babinski is noted. The patient is moving all extremities.
LABORATORY/PERTINENT DATA: CT and MRI of the head are negative
INR 1.29. CBC: White blood cell count 16.5, H&H 14.2 and 41 with platelets of 197. BMP showed a sodium of 140, potassium 3.6, chloride 101, CO2 of 25, BUN of 10 and creatinine 0.8. Blood glucose 121.
UA and UDS were both negative
Currently, the patient is still intubated and sedated with propofol. Trial in decreasing propofol was done today in which the patient failed and became combative. The patient is currently on prophylactic phenytoin. ???????????
