PATIENT IDENTIFICATION

NAME : Deepak nayak

AGE: 23 SEX: male
RELIGION: hindu
OCCUPATION : student
MARITAL STATUS: unmarried
IP NO: KIMSIP 180025 WARD: neuro-surgery icu
DATE OF ADMISSION: 20/11/2019
ADDRESS: sarapur,bhadrak
PROVISIONAL/ FINAL DIAGNOSIS: head injury with l.hemiplagia
DATE OF SURGERY,IF ANY: craniotomy
PRESENTING CHIEF COMPLAINTS: brathing difficulty,hypertention.
HISTORY OF PRESENT ILLNESS: Pt is alright befor the RTA ,complication stare when pt fall from bike on 19/1/19.
H/O LOC, vomiting, admitted to ESI hospital bhadrak..ther transfer to kims for further better treatment.
PAST HISTORY OF ILLNESS: no such clinical history of any chronic illness.
FAMILY HISTORY:
TYPE OF FAMILY:
NO OF FAMILY MEMBER:
HISTORY OF ANY ILLNESS:-
FAMILY TREE
S.N Name of the family age sex Relatio educatio occupati Marital Health
o member nship n on status status
with pt.

1 Saroj kumar nayak 52 M father 10th farmer married good

2 Aparajita nayak 48 F Mother 3rd class housewif Married good

re
3 Deepak nayak 23 M Self Hotel student unMarri Head
managm ed injury
ent
4 Anusuya nayak 21 F Sister BA Student unmarri Good
ed

 SOCIO-ECONOMIC STATUS
 Name of the place:- villege House:- own
 Type of house:- puccka Housing facility:- own
 Ventilation :- Adequate Bathroom facility:- separate
 Lighting :- electricity Latrine facility: sanitary
 Water supply: corporation Sanitation:- water seal
 Surrounding cleanliness:- clean Income per month:- family
 Source of income:- farmer
 Relationship among the family member:- good

MENTAL AND EMOTIONAL STATUS :- Psychological status of the family member is normal , stress due to
hospitalization.
PERSONAL HISTORY
Personal hygiene
 Oral hygiene: maintained
 Bath :- sponging
 Rest & sleep:- 18-22hr

DIETARY HISTORY
 General appearance: healthy Appetite: good
 Diet: non-veg No. of meals per day: 3times
 Food preferances: Fruit/ juice: 2-3 times in week
 No .of glasses of water per day: 200ml/3hr Tea/coffee:-

ELIMINATION
 Bowel:- constipetion Bladder:- continance

HABITS:
  Smoking: no Alcohol: yes
 Tobacco: yes Activity/exercises: irregular
PHYSICAL EXAMINATION
GENERAL APPEARANCE
 Level of consciousness: unconscious
 Hight :- 5ft 4inh Weight :- 62kg
 Activity :- dull
 Body built:- moderate Speech:-
VITAL SIGNS:
TEMP PULSE RESPIRATION BP
21/11/2019 99.3f 110 b / min 44b/m 160/90mmhg
22/11/2019 102.f 104b/min 43b/m 148/90mmhg
23/11/2019 101f 110b/m 46b/m 150/90mmhg

HEAD:-
 Size & shape: round
 Hair color:- black hair distribution:- normal
 Scalp: injury pediculosis: not prsent
 Swelling or tenderness:yes previous injuries:- no
FACE:
 Appearance of face : swelling Facial symmetry : normal

EYES:
 Eyes brows: normal eye lids/lashes: injury
 Eye balls: normal lacrimal sac : normal
 Conjunctiva: red sclera:- normal
 Cornea: normal pupils: normal
 Blurred vision: N/A eye discharge: yes
 Visual acuity :- N/A

EARS:
 Position: normal Ear wax: not present
 tympanic membrane: normal shape &size: normal
 Hearing acuity: N/A foreign bodies: absent
 Any discharge: no swelling: absent
 tinnitus: absent uses of hearing aids : no
 Vertigo: absent Whisper test : not done
 weber’s test: not done rinne test: not done
 Romberg test: not done any ear surgery(specify) : no

NOSE:
 Nasal symmetry: normal nasall septal deviation : normal
 Nasal discharge: absent nasal polypes: normal
 Sinusitis normal sense of smell: normal
 Any nose surgery (specify): no Epistaxis: normal
MOUTH & THROAT:
 Lips: injury shape: abnormal
  condition: normal dental caries: no
 Number of teeth : 32 dentures: no
 Gums: swelling buccal mucosa: normal
 Tongue: normal Oropharynx: normal
 Lymph node : normal thyroid: normal
 voice: N/A

RESPIRATORY SYSTEM:-
 Respiratory rate: 46b/min
 Thoracic cage: normal Configuration: normal
 Skin color and condition: normal chest expansion: symmetric
 Diaphragmatic excursion: normal lung auscultation: normal
 Breath sound: bronchial respiratory pattern normal
CARDIOVASCULAR SYSTEM:
 Pulse: 116b/m heart sound s1 s2 :-normal
 abnormal heart sound : yes BP::150/90hhmg
 Peripheral pulses: not normal murmurs: absent
 Cyanosis: present Edema: absent
 venous ulcer: absent Varicose veins: absent
GASTRO-INTESTINAL SYSTEM:
a) Inspection:
 Skin: turgor abdomen: symmetrical
 Abdominal pain: no abdominal girth:
 constipation: yes
b) Auscultation:
 Bowel sounds: normal
c) Percussion:
 Ascitis/peritonitis: absent No gas/ fluid collection: gas is present.
d) Palpation:
 Organomegaly/hepatomegaly/splenomegaly /: no
 Tenderness or indurations: present Fluid collection: no
 Masses/soft: soft
GENITO-URINARY SYSTEM:
 Urinary frequency : normal Urinary patterns: normal
 Burning patterns: absent Hematuria: absent
 Bladder distension: present Urethral discharge: No
 Bladder tenderness : absent scrotum; absent
 Testis: normal epididymis: normal
 Prostate gland: normal perineal area: normal
NEUROLOGICAL SYSTEM:
 Level of consciousness: unconsious
 Orientation: Memory/ concentration: N/A
 Communication and language skills: N/A
 Knowedge test: N/A Thinking: N/A

MUSCULO-SKELETAL SYSTEM:
 Gait: pt laying on bed posture: N/A
  Range of motion: limited Joint pain/ swelling/other: yes
 Weakness/paralysis/contracture: Lt. paralysis Muscle mass: normal
 Muscle strength: gread 2 Spine: normal
INTEGUMENTARY SYSTEM:
 Skin color: bluish discolloration Skin texture :- moist
 Skin integrity :impred Temp: warm
 Turgor / mobility elastic Edema: present
 Lesions : no Bluish discoloration: present
 Clubbing of nail : absent

SL NO TEST NAME PT.VALUE NORMAL UNITS REMARK

VALUE
1. WBC 10.03 4.00-10.00 10 3/ul
2. Neutrophils 87 40-80 %
3. Rbc counts 3.248 4.5-5.5 10 6/ul
4. HB% 8.53 13-17 %
5. PCV 27.47 40.0-50.0 %
6. MCV 84.59 83-101 1L/UM3
7. PLTC 283.8 150-410 10 3/UL
8. S.UR 64 12-43 Mg/dl
9. S.CR 0.8 0.9-1.3 Mg/dl
10. S.NA 152 136-145 Mmol/l
11. S.K 4.1 3.5-5.1 Mmol/l
12. INR 1.15
13. PT 12.4 10-15 Sec
14. APTT 20.1 30-40 sec

REDIOLOGICAL INVESTIGATION

C-X RAY
Soft tissue & bony cage of the thorax apper normal.

Normal study

2D ECHO

 CAD
 Hypokinetic LAD territory
 RWMA+
 No PE/CLOT/VEG
 MILD MR,NO AR/TR,PR

NCCT HEAD/BRAIN

 Subdural hemorrhage ovar rt.fronto-temporal parital lobe

 Hemorregeic contiusion in bi lateral temporal & right frontal.
 Midline shift towards right 6mm
 Intracranial hemorrege

DISEASE CONDITION
Disease name: HEAD INJURY WITH HEMIPLAGIA
INTRODUCTION
While the term "head injury" is most often used to refer to an injury to the brain, head injuries may also
involve the bones, muscles, blood vessels, skin, and other organs of the face or head. 
DEFINITION
A head injury is any trauma to the scalp, skull, or brain. The injury may be only a minor bump on the skull or
a serious brain injury.

REVIW OF ANATOMY & PHYSIOLOGY

 The brain is a fascinating and complex organ. It is responsible for senses, movement and control,
emotions and feelings, language and communication, thinking and memory. The brain and spinal
 cord form the central nervous system. These vital structures are surrounded and protected by the
bones of the skull and the vertebral column.
 The brain consists of four main structures: the Cerebrum, the Cerebellum, the Pons, and the
Medulla.
 The Cerebrum is the upper part of the brain and is arranged in two hemispheres called cerebral
hemispheres. The cerebrum is thought to control conscious mental processes. The outer layer of the
cerebrum is called gray matter, the inner portion, white matte
 The Cerebellum is the part of the brain located between the brain stem and the back of the
cerebrum.  The cerebellum controls muscle coordination and maintains bodily equilibrium.
 The Pons is in front of the cerebellum and coordinates the activities of the cerebrum and the
cerebellum by receiving and sending impulses from them to the spinal cord.  
 The Medulla is part of the brainstem situated between the pons and the spinal cord and it controls
breathing, heartbeat, and vomiting
 There are many other anatomical features of the brain which specialize in various activities. 
The Meninges consist of three membranes which cover the brain and spinal cord including the dura
mater, the arachnoid membrane and the pia mater. They completely surround the brain and spinal
cord.

ETIOLOGY/CAUSES
CLINICAL PICTURE PATIENT PICTURE
 motor vehicle accidents  motor vehicle accidents
  falls
 physical assaults
 sports-related accidents

RISK FACTORS

 cardiomyopathy

 coronary thrombosis

 myocarditis, or inflammation of the heart muscle

 endocarditis, or inflammation of the heart valves

 scar tissue in the heart, following surgery or a heart attack.

CLINICAL MANIFESTATION
CLINICAL PICTURE PATIENT PICTURE
 a headache  a headache
 mild confusion
 a loss of consciousness
 nausea
 vomiting
 temporary ringing in the ears
 a loss of muscle control
 a loss of consciousness
 seizures
 vomiting
 balance or coordination problems
 serious disorientation
 abnormal eye movements
 a loss of muscle control
 memory loss
 changes in mood
 leaking of clear fluid from the ear or the nose

DIAGNOSTIC EVALUATION
 CLINICAL PICTURE PATIENT PICTURE
 MRI, CT and MRA  MRI
 EEG
 The Electroencephalogram  NCCT
 PET scan
 Positron emission tomography  BLOOD INVESTIGATION
 Combined MRI & PET
 SPECT Scan
 Single-photon emission computed tomography
 Evoked potentials
 Lumbar puncture
 MRS & MRA
 Magnetic resonance spectroscopy
 Magnetic resonance angiography
 Intracranial pressure monitor
 All blood investigation & CSF study

MANAGEMENT
MEDICAL MANAGEMENT
CLINICAL PICTURE PATIENT PICTURE
 atropine  Atropine
 isoproterenol
 atropin  Inj. Claxane
 ANTI –HTN  CEFTRIAXONE SODIUM
 Sedation: profanol.  Cort-S /hydrocortisone
 Pain relief: Opioids
 Diuretics: Mannitol is the most commonly used  Inj.manitol
diuretic for TBI
 Anti-seizure medication

SURGICAL MANAGEMENT
CLINICAL PICTURE PATIENT PICTURE

 remove a hematoma  craniotomy

 repair your skull
  release some of the pressure in your skull

COMPLICATIONS
Seizures:
Infections: Meningitis can occur if there is a rupture in the meninges, the membranes around the brain.
Nerve damage:causing paralysis of facial muscles, double vision, problems with eye movement, and a loss of
the sense of smell.
Cognitive problems: People with moderate to severe TBI may experience some cognitive problems,
including their ability to:

 focus, reason, and process information

 communicate verbally and nonverbally

 judge situations

 multitask

 remember things in the short term

 solve problems

 organize their thoughts and ideas

Personality change
Problems with the senses: These may lead to:

 tinnitus, or ringing in the ears

 difficulty recognizing objects

 clumsiness, due to poor hand-eye coordination

 double vision and blind spots

 sensing bad smells or a bitter taste

Coma:.
Long-term neurological problems: depression, Alzheimer's, Parkinson's disease, and other cognitive and
neurological conditions.