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Case Presentation
Presented by:
Sagar Kishor Savale
B-pharm final year
Exame No- 528510
Department of Clinical Pharmacy
R. C. Patel Institute of Pharmaceutical Education &
Research; Shirpur.
Dist: Dhule, Maharashtra.
Date:27/04/2015.
Name Mr. xyz
Address Shirpur
Age 38 yrs
Sex Male
Weight 59 kg
Hospital name Shri Siddheshwar Multispeciality
Hospital Deopur , Dhule 424002
DOA 10/04/2014
DOD 18/04/2014
Consultant Doctor Dr. Thakar Sir And Desale sir
PATIENT PROFILE:
Occupation Shopkeeper
Social History Vegetarian
Family History Nil
Diagnosis:
Final diagnosis Head injury
Associated Disease Right Clavicle Damage
LAB DATA REPORTS
On 10th April,2014
Hb - 14 mg/dl (13.8-17.2mg/dl)
WBC - 14500 million/mm3
Creatinine - 1.3mg/dl (0.7 to 1.2 mg/dl
Urea / sugar - 102 mmol of glucose per litre
of plasma
EXAMINATION FINDINGS
CNS EXAMINATION
B.P :- 130/80 mmHg
CVS EXAMINATION
Pulse rate :- 98/min
Respiratory System Examination:
Respiaratory rate :- 18/min
Diagnosis Parameters-
1. CT scan
2. MRIscan (Magnetic resonance imaging )
3. Skull x-rays
4. Arteriography
DIAGNOSIS :-
Patients was diagnosed with head injury and right clavicle
damaged.
 Computed tomography (CT) has become the diagnostic
modality of choice for head trauma due to its accuracy,
reliability, safety, and wide availability.
Head injury
Any injury that results in trauma to the skull, or brain is known as head
injury.
Any trauma to the scalp, skull, or brain i.e. head injury
classification includes neuronal injuries, hemorrhages, vascular
injuries, cranial nerve injuries, and subdural hygromas, among many
others.
there are many causes—including accidents, falls, physical
assault, or traffic accidents ,Motor vehicle accidents , Sports-related
injuries —that can cause head injuries.
Symptoms of mild head injury :
• a mild headache
• nausea (feeling sick)
• mild dizziness
• bleeding in the brain
Signs of a severe head injury can include:
• unconsciousness – either brief (concussion) or for a
longe period of time
• fits or seizures – when the body suddenly moves
uncontrollably
• difficulty speaking or staying awake
• problems with the senses – such as loss of hearing or
double vision
• repeated vomiting
• blood or clear fluid coming from the ears or nose
• memory loss (amnesia)
Treatment
MEDICATION DETAILS
Sr.no medication dose Std.dose Frequency
1 Inj.cefabact (Ceftriaxone) 1 gm 1 gm b.i.d.
2 Inj.rantac (ranitidine) 50 mg/ml 50 mg/ml b.i.d
3 Inj.zofer (odensteron) 4 mg/ml 4 mg/ml b.i.d
4 Inj.zemisole 100ml 100ml b.i.d
5 Inj.fasolin(fosphenytoin) 750mg 750 mg b.i.d
6 Inj.dynapar (dyclofenac sodium) 25 mg/ml 25 mg/ml b.i.d
7 Tab.cefedinir 300mg 300mg b.i.d
8 Tab.rantac D 150 mg 150mg-300mg b.i.d
9 Tab.emanzen D(diclofenac) 50mg/10mg 50mg/10mg b.i.d
10 Tab.epsolin(phenytoin) 100 mg 100 mg b.i.d
11 syp.glycerol 15 ml 15 ml b.i.d
route
I.V.
I.V.
I.V.
I.V.
I.V.
I.V.
Oral
Oral
Oral
Oral
Oral
DISCUSSION
Drug Interaction:
Phenytoin has a narrow therapeutic range:
10-20 mg/L
Ranitidine increases the bioavailability of calcium channel
blockers by lowering gastric acidity.
Ranitidine when combined with furosemide, increases it’s
bioavailability.
PATIENT COUNSELING
1) To control bleeding, apply clean
dressings directly to scalp or facial
cuts.
2) To control swelling, apply ice for 20 to
30 minutes every 2 to 4 hours.
3) For headache, give over-the-counter
acetaminophen. Do not use
aspirin,ibuprofen, or other anti-
inflammatory drugs, which can increase
the risk of bleeding.
Call 911 if the person has any of the
following
symptoms:
1. Blood or clear fluids coming from the
ears or nose
2. Unconsciousness, confusion,
dizziness, or drowsiness
3.Unequal pupil size or blurred or double
vision
Preventing head injuries
Always use safety equipment during activities
that could cause a head injury. These include seat
belts, bicycle or motorcycle helmets, and hard
hats.
Learn and follow bicycle safety
recommendations.
Do not drink and drive
REFERENCES
en.m.Wikipedia.org/wiki/head injury
www.autismtreatmentindia.com
Emedicine.Medscape.com
www.healthline.com/health/head -injury
www.mayoclinic.org/.../traumatic-brain-...
www.drugdiggest.com
www.wikipedia.com
www.netdoctor.com
Thank you for listening me………

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case presentation on Head Injury

  • 1. Case Presentation Presented by: Sagar Kishor Savale B-pharm final year Exame No- 528510 Department of Clinical Pharmacy R. C. Patel Institute of Pharmaceutical Education & Research; Shirpur. Dist: Dhule, Maharashtra. Date:27/04/2015.
  • 2.
  • 3. Name Mr. xyz Address Shirpur Age 38 yrs Sex Male Weight 59 kg Hospital name Shri Siddheshwar Multispeciality Hospital Deopur , Dhule 424002 DOA 10/04/2014 DOD 18/04/2014 Consultant Doctor Dr. Thakar Sir And Desale sir PATIENT PROFILE:
  • 4. Occupation Shopkeeper Social History Vegetarian Family History Nil Diagnosis: Final diagnosis Head injury Associated Disease Right Clavicle Damage
  • 5.
  • 6. LAB DATA REPORTS On 10th April,2014 Hb - 14 mg/dl (13.8-17.2mg/dl) WBC - 14500 million/mm3 Creatinine - 1.3mg/dl (0.7 to 1.2 mg/dl Urea / sugar - 102 mmol of glucose per litre of plasma
  • 7. EXAMINATION FINDINGS CNS EXAMINATION B.P :- 130/80 mmHg CVS EXAMINATION Pulse rate :- 98/min Respiratory System Examination: Respiaratory rate :- 18/min
  • 8. Diagnosis Parameters- 1. CT scan 2. MRIscan (Magnetic resonance imaging ) 3. Skull x-rays 4. Arteriography DIAGNOSIS :- Patients was diagnosed with head injury and right clavicle damaged.  Computed tomography (CT) has become the diagnostic modality of choice for head trauma due to its accuracy, reliability, safety, and wide availability.
  • 9. Head injury Any injury that results in trauma to the skull, or brain is known as head injury. Any trauma to the scalp, skull, or brain i.e. head injury classification includes neuronal injuries, hemorrhages, vascular injuries, cranial nerve injuries, and subdural hygromas, among many others. there are many causes—including accidents, falls, physical assault, or traffic accidents ,Motor vehicle accidents , Sports-related injuries —that can cause head injuries.
  • 10. Symptoms of mild head injury : • a mild headache • nausea (feeling sick) • mild dizziness • bleeding in the brain Signs of a severe head injury can include: • unconsciousness – either brief (concussion) or for a longe period of time • fits or seizures – when the body suddenly moves uncontrollably • difficulty speaking or staying awake • problems with the senses – such as loss of hearing or double vision • repeated vomiting • blood or clear fluid coming from the ears or nose • memory loss (amnesia)
  • 12. Sr.no medication dose Std.dose Frequency 1 Inj.cefabact (Ceftriaxone) 1 gm 1 gm b.i.d. 2 Inj.rantac (ranitidine) 50 mg/ml 50 mg/ml b.i.d 3 Inj.zofer (odensteron) 4 mg/ml 4 mg/ml b.i.d 4 Inj.zemisole 100ml 100ml b.i.d 5 Inj.fasolin(fosphenytoin) 750mg 750 mg b.i.d 6 Inj.dynapar (dyclofenac sodium) 25 mg/ml 25 mg/ml b.i.d 7 Tab.cefedinir 300mg 300mg b.i.d 8 Tab.rantac D 150 mg 150mg-300mg b.i.d 9 Tab.emanzen D(diclofenac) 50mg/10mg 50mg/10mg b.i.d 10 Tab.epsolin(phenytoin) 100 mg 100 mg b.i.d 11 syp.glycerol 15 ml 15 ml b.i.d route I.V. I.V. I.V. I.V. I.V. I.V. Oral Oral Oral Oral Oral
  • 13. DISCUSSION Drug Interaction: Phenytoin has a narrow therapeutic range: 10-20 mg/L Ranitidine increases the bioavailability of calcium channel blockers by lowering gastric acidity. Ranitidine when combined with furosemide, increases it’s bioavailability.
  • 14. PATIENT COUNSELING 1) To control bleeding, apply clean dressings directly to scalp or facial cuts. 2) To control swelling, apply ice for 20 to 30 minutes every 2 to 4 hours. 3) For headache, give over-the-counter acetaminophen. Do not use aspirin,ibuprofen, or other anti- inflammatory drugs, which can increase the risk of bleeding. Call 911 if the person has any of the following symptoms: 1. Blood or clear fluids coming from the ears or nose 2. Unconsciousness, confusion, dizziness, or drowsiness 3.Unequal pupil size or blurred or double vision
  • 15. Preventing head injuries Always use safety equipment during activities that could cause a head injury. These include seat belts, bicycle or motorcycle helmets, and hard hats. Learn and follow bicycle safety recommendations. Do not drink and drive
  • 17. Thank you for listening me………