Case presentation on hemorrhage- useful for medical students, pharmacy students, for covering the case reports required during their education. Includes basic information about the disease, subjective evidence, chief complaints of the patient, vital signs, objective evidence, laboratory data, assessment, provisional diagnosis, final diagnosis, treatment chart ,planning and medications given to the patient during his/her stay in the hospital.
2. ABOUT THE DISEASE
HEMORRHAGE :- Loss of blood from damaged blood vessels.
It maybe internal or external , and usually involves a lot of bleeding
in a short time.
- Can be caused by :-
• Alcohol, drug or tobacco abuse
• Blood clotting disorders
• Cancer
• Hereditary
3. SUBJECTIVE EVIDENCE
IP NO:- 20623
AGE :- 30 years
GENDER :- Male
DEPARTMENT :- Male general ward
DOA:- 3/4/23
8. MSCT SCAN OF BRAIN
LARGE INTRA-PARENCHYMAL HEMATOMA WITH
PERILESIONAL EDEMA, BILATERAL CEREBRAL AND
CEREBELLAR EDEMA.
PROVISIONAL DIAGNOSIS :-
Hemorrhage?
9. ASSESSMENT
A 30 year old male patient was admitted to the male
ward with chief complaints of aphasic, excessive
sweating, altered sensorium since about 15 minutes,
unable to take oral medicines.
FINAL DIAGNOSIS :-
Hemorrhage
10. PLANNING
DAY 1 – 3/4/23
INJ. Levipil – 500 mg – OD
INJ. Pantopryl – 500 mg – OD
INJ . PCM – 100 cc - SOS
DAY 2 – 4/4/23
Same as day 1
DAY 3 – 5/4/23
Same as day 1
Stable vitals
INJ. Emset – 1mg - TDS