This document summarizes the case of a 44-year-old male patient admitted to the hospital with seizures, vomiting, decreased appetite, and weakness in his limbs. Lab results found increased creatinine, BUN, and decreased chloride levels. A CT scan found no abnormalities in the brain but soft tissue swelling in the frontal region. Based on the subjective and objective patient data, the patient was diagnosed with a cerebrovascular accident, hypertension, and stage 4 chronic kidney disease. The treatment plan focused on rehabilitation, medication, monitoring the patient's condition, and counseling on lifestyle changes and managing the disease.

1. CEREBRO VASCULAR ACCIDENT
By….K.SHIVAKUMAR

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

8. T.Cinmoral
forte
Trypsin,chy
motrypsin
1mg P/O BD
T.Amlodipin
e
Amlodipine 5mg P/O BD
T.Artamine Clonidine
HCl
0.1mg P/O TID
T.Met-XL Metoprolol 50mg P/O OD

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