HISTORY: A 30 year old male with a past medical history of hypothyroidism was out playing soccer when he was struck by lightening. After the lightening strike, the patient experienced cardiac arrest, and CPR was performed. Spontaneous circulation was achieved after a 17 minutes of CPR, and the patient was admitted to a burn unit for partial thickness burns of his left anterior chest, abdomen, and right medial lower calf. During the patient’s stay on the burn unit, he was noted to have severe cognitive deficits secondary to an anoxic brain injury sustained during his cardiac arrest, and also had a PEG tube placed after developing aspiration pneumonia. Following the burn unit, the patient was transferred to an acute rehab facility to address the severe cognitive deficits he had developed. Upon arrival at the acute rehabilitation facility, the patient was a Rancho Los Amigos level three. PHYSICAL EXAM: The patient was lying comfortably in bed. He was able to mimic behavior, but was unable to follow commands consistently. On ocular exam, the patient had a left pupil that was fixed and dilated, and sub-conjunctival hemorrhages. Abdominal exam was significant for an in-place PEG tube. Integumentary was significant for partial thickness wounds on his anterior chest and right lower extremity. The patient demonstrated full active range of motion of his upper and lower extremities. DIFFERENTIAL DIAGNOSIS: Anoxic encephalopathy Encephalopathy secondary to electrocution Toxic metabolic encephalopathy TESTS AND RESULTS: -Labs on admission were significant for the following: White blood cell count of 5.0; hemoglobin of 10.3; blood urea nitrogen of 55; AST of 42 and ALT of 70. -CT head on admission showed no evidence of intracranial hemorrhage, lobar infarct, hydrocephalus, or midline shift. FINAL DIAGNOSIS: Anoxic encephalopathy secondary to lightening strike TREATMENT AND OUTCOMES: The patient was started on amantadine to stimulate increased attention and wakefulness, and seroquel and trazadone to help address the patients nocturnal agitation and promote sleep. At the end of his 5 week stay on the acute rehabilitation unit, the patient had advanced to a Ranchos Los Amigos level eight. He was fully oriented to his environment, tolerating an oral diet, engaging in appropriate conversation, and ambulating with a walker.