A 60 YEAR OLD MALE WITH ?ACUTE ON CHRONIC SDH
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CASE DISCUSSION:-
A 60 year old male, farmer by occupation came to the OPD with chief complaints of
Vomiting since 15 days
Giddiness since 15 days
History of present illness:-
The patient was apparently asymptomatic 2 months back then he had alleged history of head injury following which patient went to hospital and was diagnosed with sub dural hematoma which is being treated conservatively.
Since 15 days patient had Vomiting immediately after intake of food which is non bilious and non projectile and food particles as contents.
No h/o cold, cough, fever.
No abdominal dissension or facial edema.
No loose stools
History of past illness:-
Not a k/c/o DM, HTN, epilepsy, asthma.
Personal history:-
Appetite normal
Mixed diet
Sleep normal
Bowel and bladder normal
Addictions- Smoker.
General Examination:-
The patient was examined in well lit room after taking his consent.
The patient was conscious, coherent and co operative. He was well Oriented to time, place and person
No pallor, icterus, cyanosis, clubbing, lymphadenopathy.
Vitals:-
Temperature: Afebrile
Blood Pressure:150/90 mmHg
Pulse Rate: 80bpm
SpO2: 98% at RA
GRBS: 147 mg%
Systemic Examination:-
CVS- S1, S2+
CNS-NAD
RS- BAE+, NVBS
P/A- Soft and Tender
GIT- Bowel sounds+
GCS- 15/15
Systemic Examination:-
CNS Examination:-
HMF- Intact
Cranial nerves- Intact
Sensory System-
No significant findings
R L
Vibration:
WRIST: PRESENT PRESENT
ELBOW: PRESENT PRESENT
LL: PRESENT PRESENT
Proprioception:
PRESENT PRESENT
Motor system:-
Tone:-
R L
Upper limbs: N N
Lower limbs: N N
Power:-
R L
Upper limbs: 4+ 4+
Lower limbs: 4+ 4+
Reflexes:
B T S K A
Right - 3+ 3+ 3+ 3+ 3+
Left - 3+ 3+ 3+ 3+ 3+
Plantar - Flexor
Cerebral signs:-
Finger Nose in Co ordination: No
Knee Heel in Co Ordination: No
Investigations:-
Provisional diagnosis:-
CERVICAL MYELOPATHY AND ACUTE ON CHRONIC SUB DURAL HEMATOMA
Plan of care:
INJ OPTINEURON 1 Amp in 100ml NS/IV/OD
INJ ZOFER 4mg IV/TID
Tab PAN 40mg OD
Tab ONDANSETRON CHEWABLE TABLETS TID
BP/ PR/ Temperature monitoring every 4th hourly
Updates:
Date: 4/12/2021
Soap notes
WARD - 60Y/M patient
S- No fresh complaints
O-
PT IS C/C/C
PR: 74bpm
BP: 140/80mmHg
RR- 22cpm
RS: BAE+
CVS: S1S2 +
P/A: soft,non tender
CNS: E4V5M6
B/L pupils NSRL
A-
ACUTE ON CHRONIC SUBDURAL HEMATOMA IN RIGHT FRONTOPARIETAL REGION (23MM) WITH MIDLINE SHIFT (12.4MM) TO LEFT SIDE
P-
1)Inj. OPTINEURON 1amp in 100ml NS/IV/OD
2)Inj. ZOFER 4mg/IV/TID
3)Tab. PAN 40mg /OD
4)BP, PR, Temperature monitoring 4th hourly
5)GCS Monitoring 4th hourly
6)Monitor Vitals and inform SOS
FINAL DIAGNOSIS
ACUTE ON CHRONIC SUBDURAL HEMATOMA IN RIGHT FRONTOPARIETAL REGION (23MM) WITH MIDLINE SHIFT (12.4MM) TO LEFT SIDE
Discharge summary
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