Monday, March 21, 2011

Intern Report Case Presentation 3.5

Case Presentation by Dr. Justin Kessler

Patient B.B. a 17–year-old high school football player presenting to the emergency department via EMS after collapsing to the ground unresponsive approximately 3 hours after being struck in the head without a helmet on by another player’s helmet. Initially he was dazed but was able to stand up and joke about what a “hard head he had.” He complained of a headache throughout the rest of practice and vomited once per his coach who thought it was due to the heat. PMHx significant only for acne. Patient takes Tylenol for headaches PRN after football practice. On exam patient is not responsive to name, he makes gurgling mumbles, slowly opens his eyes to painful stimuli, and only has an abnormal flexed posture does not withdraw to pain.

Physical Exam:

Vitals: BP146/92, HR 98 , RR9, Sat87% Room, Temp 37.4

HEENT: HEAD: Slight boney stepoff along the patient's right temporal area. No Scalp Lacerations.
EYES: The pupils are 7mmOD 3mm OS sluggish reactive to light,. fundoscopic exam shows evidence of swelling of optic disk ,hyperma, and loss of physiologic cupping on exam in OD only. Sclera were anicteric, conjunctiva were without palor.
EARS: Pinnae are intact bilaterally, TM are clear,no evidence of hemotympanum Bilaterally.
NOSE: No noticeable deformity, moist mucosa, no erythema, no epistaxis, discharge, no swollen turbinates.
MOUTH AND THROAT: Mucous membranes are moist,no erythema, no tonsillar exudates, no intraoral leisions of the gums, tongue, lips, or palates.
CV: S1 S2 present, regular rhythm and tachycardic rate~ 100bpm, no murmurs
Resp: Slow shallow breaths,
Abd: Soft, nondistended, BS all 4 Qs
Ext: Peripheral pulses present in all 4 limbs, cap refill <2 seconds ROM intact with passive movement of all 4 limbs. Tone increased.
Back: No tenderness to palpation throughout cervical, thoracic, and lumbar spine. No bony deformity, crepitus, or step-offs noted.
Neuro: Pt obtunded, Decorticate posturing, not opening eyes to command or name. Positive gag reflex. Absent ankle jerk bilaterally, Babinski negative bilaterally.

Lab Results: 
Electrolytes, BUN, creatinine, glucose, and CBC were all within normal limits.
12-lead ECG performed at 1550 is interpreted as revealing tachycardic normal sinus rhythm at a rate of 102 beats per minute. Axis was normal. There were no ST or T wave abnormalities to suggest myocardial ischemia or injury.

Diagnostic Studies: Head CT as Follows:


1. Following Injury in which there is later radiographic evidence on head CT of an epidural hematoma what is the estimated percentage in which there is a “lucid” period before deterioration?
A. 75%
B. 60%
C. 20%
D. 15%
E.  5%

2. In regards to a Minor Head Trauma which of the following patients would warrant CT scanof head  or prolonged emergency department observation?
A. A 23 YO male that bumped his head on a door 2 days ago, currently asymptomatic, no LOC with intact orientation, memory.
B. A 30 YO male with a minor headache after being hit in the head from a falling telephone book(for Kansas City), no vomiting no LOC
C. A 45 YO female with fall to carpeted surface wearing high heels after drinking 2 glasses of wine with no change in consciousness, intact orientation and recall.
D.A 61 YO male who tripped over a shopping cart hit head into a car door with past history of epilepsy, last seizure was >20 years ago.
E. 5 YO female running away from her brother that hit her head on a coffee table complains of headache, witnessed by mother, child consolable on scene.

3.Which of the following factors has the greatest predictive value in the Development of seizures following head trauma?
A Patient Age
B. Occipial Lobe injury
C. Glasgow coma Score <8
D. Concomitant use of  illicit drugs
E generalized brain injury.

4.Two of these Famous TBI patients are related other than the fact that they had Traumatic Brain injury which two?

A.Ken Norton
B.Ellen White
C.Natasha Richardson
D.Muhammad Ali
E.Larry Flynt
F.Phineas Gage

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