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60 yrs old male with ? acute on chronic SDH

 



A 60 YEAR OLD MALE WITH ?ACUTE ON CHRONIC SDH

This is an Online E Log book to discuss our patient's de-identified health data shared after taking his signed informed consent

Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patient's with collective current best evidence based inputs.


I've have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.


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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