A 60 YEAR OLD MALE WITH ?ACUTE ON CHRONIC SDH

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

M. K. Farhan

Roll No. 171

I've have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

DEC 1ST, 2021.

CASE DISCUSSION:-

A 60 year old male, farmer by occupation came to the OPD with chief complaints of 

• Vomiting since 15 days 
• Giddiness since 15 days

 

History of present illness:-

• The patient was apparently asymptomatic 2 months back then he had alleged history of head injury following which patient went to hospital and was diagnosed with sub dural hematoma which is being treated conservatively.
•  Since 15 days patient had Vomiting immediately after intake of food which is non bilious and non projectile and food particles as contents.
• No h/o cold, cough, fever.
• No abdominal dissension or facial edema.
• No loose stools

History of past illness:-

• Not a k/c/o DM, HTN, epilepsy, asthma.

Personal history:-

• Appetite normal
• Mixed diet
• Sleep normal
• Bowel and bladder normal
• Addictions- Smoker.

General Examination:-

The patient was examined in well lit room after taking his consent.

• The patient was conscious, coherent and co operative. He was well Oriented to time, place and person
• No pallor, interus, cyanosis, clubbing, lymphadenopathy.

Vitals:- 

• Temperature: Afebrile
• Blood Pressure:150/90 mmHg
• Pulse Rate: 80bpm
• SpO2: 98% at RA
• GRBS: 147 mg%

Systemic Examination:-

• CVS- S1, S2+
• CNS-NAD
• RS- BAE+, NVBS
• P/A- Soft and Tender
• GIT- Bowel sounds+
• GCS- 15/15

Systemic Examination:-

CNS Examination:-

HMF- Intact

Cranial nerves- Intact

Sensory System- 

No significant findings 

                               R                          L

• Vibration:
•       WRIST:      PRESENT              PRESENT
•       ELBOW:     PRESENT              PRESENT
•               LL:      PRESENT               PRESENT
• Proprioception:
•                            PRESENT             PRESENT

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

Reflexes Video:-

Cerebral signs:-

Finger Nose in Co ordination:  No 

Knee Heel in Co Ordination: No

Investigations:-

Provisional diagnosis:-

 CERVICAL MYELOPATHY AND ACUTE ON CHRONIC SUB DURAL HEMATOMA

Plan of care:

• 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 

Updates:

Date: 4/12/2021

Soap notes

WARD - 60Y/M patient

S- No fresh complaints

O- 

PT IS C/C/C

PR: 74bpm

BP: 140/80mmHg

RR- 22cpm

RS: BAE+

CVS: S1S2 +

P/A: soft,non tender

CNS: E4V5M6

B/L pupils NSRL

A-

CHRONIC SUBDURAL HEMATOMA

with COMPRESSIVE MYELOPATHY 

P-

1)Inj. OPTINEURON 1amp in 100ml NS/IV/OD

2)Inj. ZOFER 4mg/IV/TID

3)Tab. PAN 40mg /OD

4)BP, PR, Temperature monitoring 4th hourly 

5)GCS Monitoring 4th hourly 

6)Monitor Vitals and inform SOS

Questions:-

1. What could be the reason for increased Blood pressure after trauma?