INTRODUCTION:
61 year old male, farmer by occupation came to the casuality with..
CHIEF COMPLAINTS OF:
Altered state of consciousness since
1 week.
HISTORY OF PRESENT ILLNESS:
Chronic alcoholic since 20 years, regular alcohol/Toddy drinker
Patient was apparently asymptomatic 6 years back then he had giddeness and weakness of left upper limb and lower limb and he got admitted in hospital ,at that time he was diagnosed with hypertension and CT brain was done -Rt internal capsule bleed secondary to hypertension.
He was apparently asymptomatic 1 week back and he had done his work in farm and ate food during night time and went sleep then he developed episode of involuntary movements of all 4 limbs with
uprolling of eyes,
froath from mouth +
Involuntary micturition+
Tounge bite +
Shortness of breath+
Abdominal distension with tightness.
Post-ictal confusion last for 3 days
Patient was admitted in Hyderabad hospital with above complaints and At that time his
VITALS:
BP:170/100mmhg
PR:132/min
Spo2:84%.
HISTORY OF PAST ILLNESS:
K/C/O Hypertension since 6 years
No H/o diabetes,asthma ,epilepsy
INVESTIGATIONS:
RBS:310mg/dl
HbA1C:12.3
Cr:1.8
Na:138
K:35
Alb:2.7
MRI brain with venogram- Subacute Lacunar infract, Right Temporal bleed
CT chest- Atypical Pneumonia
2D echo- EF 60%
On presentation, pt was drowsy with E4V2M4
On examination:
Pt is drowsy
Febrile to touch:100.4F
PR: 112bpm
BP: 140/90 mmHg
Spo2:84% and 95% with 15L of O2
GRBS:238mg/dl
CVS: S1, S2 heard
RS: BAE present ,B/L coarse crepts present in all areas
P/A: soft ,non tender ,bowel sounds present
CNS: E4V2M4
Tone : normal b/l
Reflexes:
Lt. Rt
B. 3+. 3+
T. 3+. 3+
S. 1+. 1+
K 3 +. 3+
A. 3+. 3+
Investigations:
On 30/09/21:
ABG
CBP
HEMOGRAM
SERUM ELECTROLYTES
SERUM CREATININE
BLOOD UREA
Radiological investigations:
PROVISIONAL DIAGNOSIS:
?Seizures secondary to Intracranial bleed ,
?Atypical Pneumonia ,Denovo DM
Plan of care:
1)Head end elevation
2)O2 inhalation to maintain Spo2 >94%
3)Tab.PCM 650 mg RT/TID
4)Tab.Levipil 500mg RT/TID
5)Tab.Montair-LC RT/OD
6)PULMOCLER RT/OD
7)Clindamycin 300mg/PO/TID
8)Tab.Librium 25 mg /PO/OD
9)Tab.Stamlo 5mg/PO/OD
9)Nebulization with Budecort 6th hrly
Ipravent 2nd hrly
10) Monitoring vitals 4th hrly
11) GRBS charting 6th hrly
12)I/O and Temperature charting
Plan of care:
*SOAP NOTES-02/10/21
A 61 YEAR OLD MALE
S-
pt was drowsy with E4V2M4
Objective
Pt is drowsy
Afebrile
PR: 93bpm
BP: 140/100 mmHg
GRBS:243mg/dl
CVS: S1, S2 heard
RS: BAE present ,B/L coarse crepts present in all areas
P/A: soft ,non tender ,bowel sounds present
CNS: E4V2M4
Tone : normal b/l
Reflexes:
Lt. Rt
B. 3+. 3+
T. 3+. 3+
S. 1+. 1+
K 3 +. 3+
A. 3+. 3+
ASSESSMENT-
?Seizures secondary to Intracranial bleed ,
?Atypical Pneumonia ,
With k/c/o HTN
Denovo DM
Plan of care:
1)Head end elevation
2)O2 inhalation to maintain Spo2 >94%
3)INJ.levofloxacin 500 mg iv/od
4)INJ.hai s/c tid
5)Tab.PCM 650 mg RT/TID
6)Tab.Levipil 500mg RT/TID
7)TAB.PULMOCLER RT/OD
8)TAB.Clindamycin 300mg/RT/TID
9)TAB.LEVIPIL 500 Mg RT/TID
10)Tab.Stamlo 5mg/PO/OD
11)Nebulization with Budecort 6th hrly
Ipravent 2nd hrly
12) Monitoring vitals 4th hrly
13) GRBS charting 6th hrly
14)I/O and Temperature charting
15) Chest physiotherapy
*Soap notes-03/10/21
S-
pt was drowsy with E4V2M4
Objective
Pt is drowsy
Afebrile
PR: 95bpm
BP: 140/100 mmHg
GRBS:169mg/dl
CVS: S1, S2 heard
RS: BAE present ,B/L coarse crepts present in all areas
P/A: soft ,non tender ,bowel sounds present
CNS: E4V2M4
Tone : normal b/l
Reflexes:
Lt. Rt
B. 3+. 3+
T. 3+. 3+
S. 1+. 1+
K 3 +. 3+
A. 3+. 3+
ASSESSMENT-
?Seizures secondary to Intracranial bleed ,
?Atypical Pneumonia ,
With k/c/o HTN
Denovo DM
Plan of care:
1)Head end elevation
2)O2 inhalation to maintain Spo2 >94%
3)INJ.levofloxacin 500 mg iv/od
4)INJ.hai s/c tid
5) INJ Mannitol
6)Tab.PCM 650 mg RT/TID
7)Tab.Levipil 500mg RT/TID
8)TAB.PULMOCLER RT/OD
9)TAB.Clindamycin 300mg/RT/TID
10)TAB.LEVIPIL 500 Mg RT/TID
11)Tab.Stamlo 5mg/PO/OD
12)Nebulization with Budecort 6th hrly
Ipravent 2nd hrly
13) Monitoring vitals 4th hrly
14) GRBS charting 6th hrly
15)I/O and Temperature charting
16) Chest physiotherapy
*Soap notes-04/10/21
S- pt is drowsy
Objective:
Pt is drowsy
Afebrile
PR:96 bpm
BP: 130/90 mmHg
CVS: S1, S2 heard
RS: BAE present ,B/L coarse crepts present in all areas
P/A: soft ,non tender ,bowel sounds present
CNS: E4V2M4
Tone : normal b/l
Reflexes:
Lt. Rt
B. 3+. 3+
T. 3+. 3+
S. 1+. 1+
K 3 +. 3+
A. 3+. 3+
ASSESSMENT-
?Seizures secondary to Intracranial bleed ,
?Atypical Pneumonia ,
With k/c/o HTN
Denovo DM
Plan of care:
1)Head end elevation
2)O2 inhalation to maintain Spo2 >94%
3)INJ.levofloxacin 500 mg iv/od
4)INJ.hai s/c tid
5) INJ Mannitol
6)Tab.PCM 650 mg RT/TID
7)Tab.Levipil 500mg RT/TID
8)TAB.PULMOCLER RT/OD
9)TAB.Clindamycin 300mg/RT/TID
10)TAB.LEVIPIL 500 Mg RT/TID
11)Tab.Stamlo 5mg/PO/OD
12)Nebulization with Budecort 6th hrly
Ipravent 2nd hrly
13) Monitoring vitals 4th hrly
14) GRBS charting 6th hrly
15)I/O and Temperature charting
16) Chest physiotherapy
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