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.

1. CASE PRESENTATION ON
HEMORRHAGE
PRESENTED BY : MANSI PANCHAL
SWAMINARAYAN UNIVERSITY
PHARMD

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

4. REASONS FOR ADMISSION
C/O:-
- aphasic, excessive sweating present
- Altered sensorium
- Unable to take oral medicines

5. VITAL SIGNS
 TEMPERATURE : normal
 PULSE RATE: 82 beats per minute
 BLOOD PRESSURE: 270/170 mmhg
 RESPIRATION RATE :- 20 cycles per minute
 SpO2 : 97%
 CVS : normal M1-M2
 RS:- clear

6. LABORATORY DATA
PARAMETERS PATIENT’S VALUE NORMAL
RANGE
4/4 6/4 7/4
Hemoglobin 14.8 13.3 11.8 13.5-18g/dl
WBC count 12250 13450 12330 4000-10000/ul
Neutrophils 62 81.5 82.5 30-70%
Lymphocytes 27.5 7.5 5.5 20-40%
Eosinophils 5 3 3.2 0-7%
Monocytes 4.7 7.7 8.6 <10%
Basophils 0.6 0.3 0.2 <1%
Platelet count 313000 190000 230000 150000-
450000/ul
RBCs 5.05 4.52 4 4.7-
6*10^6/mm^3

7. PARAMETERS PATIENT’S VALUE NORMAL
RANGE
4/4 6/4 7/4
PCV 43.48 40.09 35.72 42-52%
MCV 86.1 88.7 89.3 76-90 fl
MCH 29.4 29.4 29.5 25-31pg/cell
MCHC 34.2 33.1 33 33-35 g/dl
Smear Normocytic,
Normochromic
Normocytic,
Normochromic
Normocytic,
Normochromic
Sodium 139 133 133 135-145
mmol/l
Potassium 3.50 3.70 4.70 3.5-5.5 mmol/l
S. Creatinine 1.28 1.56 1.53 0.5-1.5 mg/dl
SGPT 28 30 31 0-49u/l

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

11. Treatment chart

12. ABOUT MEDICATIONS
1)INJ ZOSTUM :- For intra-abdomen infection.
2)INJ PACTIVE :- to treat fever.
3)INJ LEVIPIL :- to treat and prevent seizures.
4)INJ EMSET :- anti-emetic
5)INJ PANTOPRYL :- to treat Gastrointestinal reflux
disease(GERD)
6)INJ MANNITOL :- diuretic
7)NORMAL SALINE :- for dehydration and dilution