2. SUBJECTIVE DATA
A male patient of age 44 years old was
admitted in the hospital on 26/7/17 with chief
complaints of :
One episode of seizures for 3min on 25/6/17
Vomiting since 2days:15-20 episodes
Decreased appetite
H/o difficulty in walking and weakness of limbs
H/o present illness:
o Loss of appetite since 5days
o k/c/o seizure disorder and on T.eptoin(100mg) since
3years
H/o past illness:
k/c/o HTN since 3 months
3. OBJECTIVE DATA
Department of biochemistry :
Day 1 Day 2 Normal values
Creatinine 4.0mg/dL 3.9mg/dL 0.9-1.3mg/dL
BUN 26mg/dL 22mg/dL 6.0-20.0mg/dL
s.Chloride 75mmol/L 72mmol/dL 98-107mmol/dL
PROVISIONAL DIAGNOSIS:
Metabolic Encephalopathy.
HTN.
CKD-stageIV
4. DEPARTMENT OF HEMATOLOGY:
abnormal Normal
PCV 37.3% 40.0-50.0%
MCHC 36.7g/L 31.5-34.5g/L
Total count 19,400cells/ 4,000-10,000
cu.mm
Differential count:
neutrophils 87% 40-75%
lymphocytes 10% 20-40%
5. ECG:
Probably MI(lateral)
Incomplete right bundle branch block.
Slightly depressed ST segment(lateral,anterior)
ST segment depression(inferior).
Negative T wave(lateral).
prolonged QT
Probably abnormal ECG.
CT scan of brain:
No abnormality detected inn brain at present study.
Soft tissue swelling in frontal region.
6. ASSESMENT:
Based on subjective and objective data, it was
finally diagnosed as cerebro vascular accident.
PLAN
TREATMENT GOAL:
Maximize persons functional abilities and level of
independence.
Provide intensive rehabilitation.
Provide extensive training and education for the person
and the family about the disease and medications.
Rebuilt persons quality of life.
7. TREATMENT
Drug Generic
name
Dose Route Frequency
Inj.Levipil Levetirace-
tam
500mg IV BD
Inj.Optineuro
n
vitB complex 1 Amp in
100ml Ns
IV -
Inj.pan Pantaprazol
e
40mg IV OD
T.cilaheart Cilnidipine 10mg P/O BD
T.Librium Chlordiazep
oxide
25mg P/O BD
T.Telma Telmisartan 40mg P/O OD
Syp.Potchlor KCl 25ml P/O TID
9. MONITORING PARAMETERS:
EEG monitoring can be useful to detect different
brain states.
Tran jugular Doppler monitoring.
Brain tissue oxygen monitoring.
Level of consciousness, respirations, motor ability
and strength.
Other monitoring-Head CT sacn,MRI.
10. PATIENT COUNSELLING:
Because of injury to brain from stoke pt may notice
problems with changes in behavior, memory,
muscle spasm, paying attention, swallowing,
talking, thinking and depression is common.
Take the medicines as per prescription.
Diet-Avoid salty and fatty foods.
Smoking and Alcohol consumption should be
ceased.
Try to stay away from stressful conditions.
Call the doctor if u have any problem because of
drugs