GENERAL MEDICINE E - LOG BOOK

1st December 2021

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 Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

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ARUSHI KUMARI 

Roll no. 151 

60 YEAR OLD MALE WITH ACUTE ON CHRONIC SUBDURAL HEMATOMA 

A 60 year old male , farmer by occupation presented to the OPD on 30th November with chief complain of recurrent episodes of vomiting and giddiness .

History of Presenting Illness

 - Patient was apparently asymptomatic 15 days ago then he started to vomit after every meal preceded headache , mild giddiness and heat sensation on his forehead .

- Patient complaint of giddiness follwed by vomiting for 10-15 mins .

Past History

- History of trauma on scalp  4 month back following by swelling and bleeding .

- bleeding stopped within sometime after applying icepack .

- History of fight 2 months ago due to which he got injury on left temporal region. He visited RMP and doctor prescribed antihypertensives which he took for 2 days and then stopped ( as said by patient ) 

- History of repeated vomiting from 15 days because of which patient became very weak and was not able to walk .

- So the relative themselves kept a catheter 15 days back  for convenience as he had repeated vomiting and was not able to walk .

- Not a known case of Asthma, HTN , epilepsy , diabetes , thyroid , TB .

PERSONAL HISTORY

- Appetite normal

- Mixed diet  

- Sleep is adequate 

- Bowel and bladder movements are              normal

- history of allergic reaction on upper             gluteal region 20 days back which               subsided within 4-5 days by applying            ointment by local doctor

  - Same episode of allergic reaction since      1 year ( 4 times in last 1 year ) 

   - Chronic smoker from last 40 years               ( stopped since 15 days ) 

 

GENERAL EXAMINATION

Patient was examined in well lit room with his consent .

Patient is conscious ,coherent and cooperative 

Patient is well oriented to time and place

Moderately built and nourished

Pallor:absent

Icterus: absent

Clubbing:absent

Cyanosis:absent

Lymphadenopathy: absent

Edema: absent

VITALS

Temperature: afebrile

Pulse: 60 / min

Respiratory rate : 18 bpm

Blood pressure : 160/100 

SpO2 at room air : 98 per cent 

GRBS : 147 mg/dL

SYSTEMIC EXAMINATION 

Cardiovascular system

s1 and s2 heard ,no murmurs 

Respiratory system

Central position of trachea 

Vesicular breath sounds

No wheeze,no dyspnea

Abdominal examination

Scaphoid shape

No tenderness

No palpable masses

No bowel sounds

CNS EXAMINATION

 HMF : intact 

Cranial nerve : intact 

                                  R                          L

• Vibration
•    Wrist          PRESENT      PRESENT                    
•  Elbow         PRESENT     PRESENT                      
•  LL                PRESENT     PRESENT                             
• Proprioception    P              P                                 

Motor system:-

Tone :

                             R                               L

Upper limbs:       N                               N

Lower limbs:       N                                N

Power:-

                             R                                 L

Upper limbs:     4+                                4+

Lower limbs:     4+                                4+

Reflexes:

                               B       T       S        K      A

Right -                   3+      3+     3+      3+     3+

Left   -                   3+      3+     3+      3+     3+

Plantar -  Flexors

INVESTIGATION :

                    Done on 01/12/21 

                  Done on 01/12/21

             Done on 01/12/21

             Done on 01/11/21 ( at 7:04 a.m )

On 01/12/21 at 7:00 a.m 

CBP :

Hb - 9.9 

TLC - 5,600

PLT - 1.96 L

CBP at 1:00 a.m 

Hb - 10.4 

TLC - 6,600

PLT - 2.11 L

Serum electrolytes

Na+ - 148

K+ - 3.5

Cl - 95

CUE 

Albumin - ++

FBS - 95mg/dL

Serum Creatinine - 1.0 mg/dL

Blood urea - 39 mg/dL

              Done on 01/12/21 

OPHTHALMOLOGY REFERRAL 

( 01/12/21 )

                           R                   L

Lids                    N                  N

Conjunctiva      quiet          quiet 

Cornea               clear          clear

Pupil                drug              drug 

                   mydriasis        mydriasis

Lens              Early Lo         Early Lo

Dilated Funds Examination

                         R                      L 

         gross tessellation +      gross                                                                  tessellation +

Disc        N disc , circular       blurring of                                                         nasal margins 

               well defined             pale disc      

                margins                 N site , circular 

CDR  0.3-0.4 : 1    

Vessels          N                         N 

Macula      FR dull              not seen 

Impression : No features of raised ICT                                noted .

                    MRI Report 

CLINICAL PICTURE

Provisional Diagnosis : Acute on chronic                                          subdural hematoma

TREATMENT :

  

DAY 1 :

• INJ OPTINEURON 1 Amp in 100ml NS/IV/OD
• INJ ZOFER 4mg  IV/TID
• Tab PAN 40mg OD
• Tab ONDANSETRON CHEWABLE TABLETS TID
• BP/ PR/ Temperature monitoring  every 4th hourly 
• Dextrose Saline 2 unit 
•  100 mL Normal saline 

DAY 2 :

  

        Inj. OPTINEURON 1 amp in 100 mL    IV/ID 

Inj. ZOFER 4 mg IV/ TID 

Tab PAN 40 mg OD 

BP : 120/70 mmHg 

PR : 62