2. History
• 67 year old male, K/C/O DM, HTN for past 10 years who was
diagnosed with carcinoma lower alveolus, underwent left
segmental mandibulectomy + B/L SND + ALT flap
reconstruction under GA on 30/10/23. Patient was extubated
on 31/10 / 23
• Next day patient had a sudden episode of desaturation
followed by bradycardia and hypotension for which he was re-
intubated and shifted MICU on 1/11/23
• Following these events patient had an episode of GTCS which
lasted for 1 minutes. Patient was treated with midazolam 3mg
iv, and started on anti epileptics.
3. • MRI brain was done but didn’t see any significant
abnormalities. Post seizure episode patient started having
myoclonus jerks which was generalised initially but later
became localised to face and occasionally right hand. Patient
was started on midazolam infusion @2mg/hr , sodium
valproate 500 mg BD, Levitracetam 1g iv BD and clonazepam
1mg BD. But patient continued to have localised myoclonic
jerks. Levitracetam dose was increased to1.5g iv BD.
Following which myoclonus stopped.
4. • Patient continued to have poor sensorium. (E1VTM1) . MRI
brain was repeated which also did not see any significant
changes. EEG showed features of myoclonic jerks.
Hypotension improved over time and inotropic were
discontinued. Patient underwent tracheostomy on 2/11/23.
Currently patient is on T piece with O2@4L/min. Midazolam
infusion was stopped to assess the sensorium and was found
to be E2VTM3, He developed persistent high grade fever on
8/11/23. All invasive lines reviewed and revised. Antibiotic
escalated to meropenem after sending blood DTA and urine
culture.
5. GENERAL PHYSICAL EXAMINATION
• Vegetative state
• Myoclonic jerks present over face
• 15 cm surgical incision with staplers present in the midline over the
mandible and neck
• 8mm ID TT in situ Day- on T piece Day 6
• Ryles tube 14F in situ Day Day 7
• Silicone urinary catheter in situ Day 2
• 18 G ivc in situ on left UL day 2
• 15 cm incision scar present on left thigh
• DVT pump in situ
• Febrile
6. Vitals
• HR – 70/ min
• BP- 84/ 60 MM Hg right upper limb, supine position
• RR -34/min
• JVP not elevated
7. Central Nervous System examination
• Vegetative
• E2VtM2
• Four score- 7
• HIGHER FUNCTIONS
1. Level of consciousness- vegetative
2. Appearance and behaviour-
3. Emotional state (euphoria, depression, hostile) – Couldn’t be tested
4. Orientation with time, place and person- Couldn’t be tested
5. Illusion, delusion or hallucination - Couldn’t be tested
6. Memory - Couldn’t be tested
7. Intelligence - Couldn’t be tested
8. Speech (with handedness) - Couldn’t be tested
8. • Cranium and spine: Normal
• Neck rigidity – absent
• KERNIG’S sign. BRUDZINSKI’S sign. – can’t be performed
• Examination of carotid arteries– Normal, No bruit
9. EXAMINATION OF CRANIAL NERVES
1. Olfactory- Couldn’t be tested
2. Optic- Couldn’t be tested
i) Acuity of vision
ii) Field of vision
iii) Colour vision
iv) Ophthalmoscopy or fundoscopy (not done)
10. • 3. Oculomotor, 4. trochlear and 6. abducens-
i. No Ptosis
ii. No Squint
iii. No Enophthalmos or exophthalmos
iv. Extra ocular movements- Couldn’t be assessed
v. Nystagmus – Absent
vi. Pupil- 2mm bilateral, Reaction (light reflex , consensual light reflex-
Present bilaterally and accommodation reflex couldn’t be assessed
)
11. 5. Trigeminal
i. Motor function (masseter, pterygoids and temporalis) – Couldn’t be
assessed
ii. Sensory function (sensation over the face) – Couldn’t be assessed
iii. Corneal reflexe present bilaterally
iv. Jaw reflex – absent
7. Facial nerve –
i. Palpebral fissure, frowning, symmetry of blinking, eye closure,
nasolabial folds, angle of the mouth, blowing, whistling, showing
the teeth, epiphora, dribbling of saliva
ii. Power of individual facial muscle– Couldn’t be assessed
iii. Upper half of face escaped or not– Couldn’t be assessed
12. 8. Vestibulocochlear – couldn’t assesss
i. Hearing- Watch test, Rivne’s test, Weber test
ii. Positional nystagmus
9, 10. Glossopharyngeal and vagus – couldn’t assess
i. Soft palate- movement on saying aah
ii. Pharyngeal or gag reflex
iii. Taste sensation posterior 1/3 rd of tongue
11. Spinal accessory – Couldn’t be assessed
i. Power of sternocleidomastoid
ii. Power of trapezius
13. • 12. Hypoglossal – Couldn’t be assessed
i. Power of tongue muscle
ii. Deviation
iii. Atrophy/ fasiculations
14. MOTOR FUNCTION EXAMINATION
a) Nutritional status- Moderately built and nourished
b) Tone
i. UL- normal
ii. LL - normal
c). Power
i. UL- couldn’t assesss
ii. LL- couldn’t assess
d). Coordination
i. UL- couldn’t assess
ii. LL-couldn’t assess
e.) Involuntary movements– Myoclonic jerks + over the face
15. f). Reflexes
i. Superficial
1. Abdominal
• Upper – absent
• Middle – absent
• Lower – absent
2. Cremasteric – not done
3. Anal – not done
4. Plantar reflex R- plantar flexor and withdrawal, L- flexor
18. Sensory system examination
a). Superficial – couldn’t be assessed
1. Pain
2. Touch
3. Temperature
b). Deep- couldn’t be assessed
1. Pressure
2. Vibration
3. Proprioception
4. Position sense
19. c) Cortical – couldn’t be assessed
1. Tactile localisation
2. 2 point discrimination
3. Stereognosis
4. Graphaesthesia
5. Sensory in attention
Cerebellar function- Titubation, scanning speech, dysdidachokinesia, finger
nose test- couldn’t be assessed
nystagmus – absent
20. Autonomic function – temperature regulation, postural
hypotension,abnormal sweating, horners syndrome
Gait- couldn’t be assessed
Trophic changes - absent
Peripheral nerve – Thickening or tenderness – absent
21. Other system examination
• Respiratory system- Normal vesicular breath sounds, No added
sounds
• Cardiovascular system- S1S2 present, No murmur
• Gastrointestinal system- soft, non tender, Bowel sounds present
23. Summary
• 67 year old male,who is a K/C/O DM, HTN diagnosed with carcinoma
lower alveolus, underwent left segmental mandibulectomy + B/L SND
+ ALT flap reconstruction, developed bradycardia and hypotension
within 24 hrs of extubation. ROSE obtained within 5 mins.
