A 61Y/M Acute CVA - ( acute hemorrhagic infarct ) - Right temporal lobe hemorrhage .with tiny hemorrhagic foci in bilateral cerebellar hemisphere,brainstem ,basal gangilia, seizures secondary to CVA , Aspiration pneumonia and denovo diabetes.

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I 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.

61 year male farmer , 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.

Patient came to casuality with Altered state of consciousness since 1 week .

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%

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

K/C/O Hypertension since 6 years

No H/o diabetes,asthma ,epilepsy

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+

Clinical images:

Investigations:

On 29/09/21:

On 30/09/21:

On 02/10/21:

On 03/10/21:

Radiological investigations:

Ct report:

MRI report:

Provisional diagnosis:

1- Acute CVA - ( acute hemorrhagic infarct ) - Right temporal lobe hemorrhage with tiny hemorrhagic  foci in  bilateral cerebellar hemisphere,brainstem ,basal gangilia

2- seizures secondary to CVA .

3- Aspiration pneumonia

4- 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)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-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)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-05/10/21

S- pt is drowsy

 Objective:

     Pt is  drowsy

     Afebrile

     PR:100 bpm

     BP: 110/90 mmHg

     GRBS:161 mg/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-

1- Acute CVA - ( acute hemorrhagic infarct ) - Right temporal lobe hemorrhage .with tiny hemorrhagic  foci in  bilateral cerebellar hemisphere,brainstem ,basal gangilia

2- seizures secondary to CVA .

3- Aspiration pneumonia

4- Denovo diabetes

         

   Plan of care:

    1)Head end elevation

    2)O2 inhalation to maintain Spo2 >94%

    3)INJ.hai s/c tid

    4)Tab.PCM 650 mg RT/TID

    5)Tab.Levipil 500mg RT/TID

    6)TAB.PULMOCLER RT/OD

    7)TAB.Clindamycin 300mg/RT/TID

    8)TAB.LEVIPIL 500 Mg RT/TID

   9)Tab.Stamlo 5mg/PO/OD

   10)Nebulization with Budecort 6th hrly

                                     Ipravent 2nd hrly

   11) Monitoring vitals 4th hrly

   12) GRBS charting 6th hrly

   13)I/O and Temperature charting

    14) Chest physiotherapy

*Soap notes-06/10/21

   S-pt is drowsy

   Objective:

     Pt is  drowsy

     Afebrile

     PR:74 bpm

     BP: 100/60 mmHg

     GRBS:219 mg/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-

           1- Acute CVA - ( acute hemorrhagic infarct ) - Right temporal lobe hemorrhage .with tiny hemorrhagic  foci in  bilateral cerebellar hemisphere,brainstem ,basal gangilia

2- seizures secondary to CVA .

3- Aspiration pneumonia

4- Denovo diabetes                 

         

   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) Syrup Ascoril

   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 -07/10/21

AMC - 1st BED

Soap notes-07/10/21

   S- pt is drowsy

   Objective:

     Pt is  drowsy

     Afebrile

     PR:70 bpm

     BP: 120/70 mmHg

     GRBS:137 mg/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-

           1- Acute CVA - ( acute hemorrhagic infarct ) - Right temporal lobe hemorrhage .with tiny hemorrhagic  foci in  bilateral cerebellar hemisphere,brainstem ,basal gangilia

2- seizures secondary to CVA .

3- Aspiration pneumonia

4- Denovo diabetes                 

         

   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) Syrup Ascoril

   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 -08/10/21

    

Ward case

Soap notes-08/10/21

    S-pt is drowsy

    Objective:

     Pt is  drowsy

     Afebrile

     PR:96 bpm

     BP: 120/80 mmHg

     GRBS:120 mg/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-

           1- Acute CVA - ( acute hemorrhagic infarct ) - Right temporal lobe hemorrhage .with tiny hemorrhagic  foci in  bilateral cerebellar hemisphere,brainstem ,basal gangilia

2- seizures secondary to CVA .

3- Aspiration pneumonia

4- Denovo diabetes                 

         

   Plan of care:

    1)Head end elevation

    2)O2 inhalation to maintain Spo2 >94%

    3)INJ.hai s/c tid

    4) Tab. Azithmol RT/OD

    5)Tab.PCM 650 mg RT/TID

    6)Tab.Levipil 500mg RT/TID

    7)Tab.Stamlo 5mg/PO/OD

     8) TAB prega M 25mg/RT/H/S

     9)Nebulization with Budecort 6th hrly

                                         Ipravent 2nd hrly

   10) Monitoring vitals 4th hrly

   11) GRBS charting 8th hrly

   12)I/O and Temperature charting

    Planning for discharge