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Stroke

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  • 1. A 64 years male patient was admitted to the hospital with  Chief complaints: one episode of syncope, loss of memory ocassinally muscle weakness, altered breathing and heart rate.  Past medical history: type -II diabetes mellitus ( from past 3yrs)  Social history:  ONGOING EXAMINATIONS: smoker, alcohol consumer Investigation Observed value Normal value B.P 130/80 mmHg 120/80mmHg P.R 110/min 72/min TEMP 98.4F 98.3F
  • 2.  LBORATORY INVESTIGATIONS: HAEMATOLOGY Investigation Observed value Normal value Hb 13.6gm% 12-16gm% RBC 4.8micells/cumm 3.5-4.5micel/cumm WBC 7700cells/cumm 4000-11000c/cumm PLATELETS 1.8LAK 2-3LAK DIFFERENTIAL COUNT Investigation Observed value Normal value Polymorphs 55% 40-75% Lymphocytes 38% 20-45% Eosinophils 5% 1-6%
  • 3. biochemistry Investigation Observed value Normal value R.B.S 282mmol/L 135-145mmol/L F.B.S 155mg/dl 75-100mg/dl Urine examination Investigation Normal value PH 5.2 5-80 Specfic gravity 1.010 1.010-1.030 Urine sugar Nill Nill u.Albumin  Observed value Nill nill CT SCAN and MRI SCAN were done
  • 4. (White areas indicate hyperdensity = blood) Large left frontal intracerebral hemorrhage. Intraventricular bleeding is also present No fibrinolytics!
  • 5.  DIAGNNOSIS :  TREATMENT: CEREBRO VASCULAR ACCIDENT DIABETES MELLITUS GENERIC NAME BRAND NAME DOSE FREQUENCY ROUTE OF ADM. Pantaprazole Inj.pantop 40mg OD IV Ondansetron Inj.periset 8mg S0S IV Aspirin Tab.dispirin 350mg OD IV Atorvastatin Tab.storvas 40 mg H2S ORAL Piracetam Tab.nootro PR 120mg TID ORAL Valproic acid Tab.somazina 500mg BD IV Insulin Inj.insugen 10units BD IV
  • 6. SOAP analysis: Problem 1: Cerebro vascular accident subject: chief complaints of one episode of syncope, loss of memory , weakness. CVA conformation done by MRI scan report (hemorrhage) object: assessment: - For reducing the cerebro cortical insufficiency ,neurotonics was prescribed. - For reducing the depression, Antiepileptic drug was prescribed. -For reducing the hemorrhagic condition, antiplatelet drug was prescribed. Plan: Tab.piracetam-120mg thrice daily. Tab.valproic acid-500mg twice daily. Tab.dispirin- 350mg once daily.
  • 7. Problem 2: Diabetes mellitus Subject: patient with known case of diabetes mellitus from past 3yrs. Object: the abnormal lab. Reports found to be Investigation Observed value Normal value F.B.S 155mg/dl 75-100mg/dl R.B.S 282mg/dl 135-145mg/dl Assessment: for reducing the blood sugar levels insulin was prescribed. Plan: Inj.insugen-10 units twice daily.