Skip to main content

25M with TBI SECONDARY TO RTA WITH IVH

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 


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. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.


For detailed clinical history and examination and clinical images:



DISCHARGE SUMMARY


Diagnosis


1)RTA TRAUMATIC BRAIN INJURY (20/03/23) WITH INTRA VENTRICULAR HEMORRHAGE


(RESOLVED) WITH FRONTAL BONE FRACTURE S/P RIGHT FRONTAL LACERATION WITH SOFT TISSUE REPAIR WAS DONE ON 21/03/23


2) POST CPR HIE


3)S/P TRACHEOSTOMY 29/3/23)EXTUBATED ON (30/3/23) AT 8PM


4)HFMEF 50% ANTERIOR WALL MI


5) GRADE 2 BEDSORE


6) VENTILATOR ASSOCIATED PNEUMONIA (RESOLVING WITH BILATERAL PLEURAL



Case History and Clinical Findings


CHEIF COMPLAINTS


PATIENT ALLEGED TO FALL FROM BIKE UNDER ALCOHOL INFLUENCE ON 20/03/13


HOPI


PATIENT HAD A FALL FROM BIKE UNDER ALCOHOL INFLUENCE AT 9.30PM NEAR HALIYA ON 20/03/23 THEN WAS TAKEN TO A HOSPITAL FOR FURTHER MANAGEMENT, PATIENT WAS INVESTIGATED AND DIAGNOSED TO HAVE RTA TRAUMATIC BRAIN INJURY WITH INTRA VENTRICULAR HEMORRHAGE WITH FRONTAL BONE FRACTURE WITH ASPIRATION PNEUMONIA AND RIGHT FRONTAL LACERATION WITH SOFT TISSE REPAIR AND DEBRIDEMENT WAS DONE ON 21/03/23 PATIENT WAS INTUBATED ON 20/03/23 I/VIO POOR GCS AND EXTUBATED ON 21/02/23 PATIENT HAD SUDDEN CARDIAC ARREST AT 7.30AM ON 25/03/23 AND WAS AGAIN REIN TUBATED AFTER 2 CYCLES OF CPR, ROSC ACHEIVED AND IS CONNECTED TO MECHANICAL VENTILATOR WITH FI02 100% PATIENT HAD FOCAL SEIZURES S/O HIE WITH STRESS MYOCARDITIS AND IS ON IONOTROPES SUPPORT ET CULTURE SHOWED (21/02/23) KLEBSIELLA WITH INTERMEDIATE SENSITIVITY TO INJ AZTREONEMPATIENT WAS SHIFTED TO OUR HOSPITAL FOR FURTHER MANAGEMENT.


PAST HISTORY


NOTA K/C/O HTN/DM/TB/CVA/CAD/EPILEPSY/THYROID DISORDER


PERSONAL HISTORY:


DIET MIXED


APPETITE NORMAL


SLEEP NORMAL


BOWEL AND BLADDER REGULAR ADDICTIONS OCCASIONAL ALCOHOL CONSUMPTION


NO ALLERGIES


FAMILY HISTORY INSIGNIFICANT


GENERAL EXAMINATION


PATIENTIS CONSCIOUS COHERENT AND COOPERATIVE


MODERATELY BUILT AND NOURISHED NO SIGNS OF PALLOR ICTERUS CYANOSIS CLUBBING LYMPHADENOPATHY, EDEMA


VITALS


AFEBRILE


PR-120BPM


BP-130/80 MMHG


RR-22 CPM


SPO2-100% ON F102


GRBS-132M5%


SYSTEMIC EXAMINATION PER ABDOMEN


INSPECTION


ABDOMEN IS SCAPHOID UMBILICUS IS CENTRAL


ALL QUADRANTS ARE MOVING EQUALLY WITH RESPIRATION NO SINUSES ENGORGED VEINSVISIBLE PULSATIONS


HERNIAL ORIFICES ARE FREE


PALPATION


NO LOCAL RISE OF TEMPERATURE


NO TENDERNESS


LIVER AND SPLEEN-NOT PALPABLE PERCUSSION TYMPANIC NOTE HEARD OVER THE ABDOMEN


FLUID THRILL ABSENT


SHIFTING DULLNESS ABSENT


AUSCULTATION


BOWEL SOUNDS ARE HEARD.


CARDIOVASCULAR SYSTEM


INSPECTION SHAPE OF CHEST IS ELUPTICAL NO RAISED JVP NO VISIBLE PULSATIONS SCARS, SINUSES, ENGORGED VEINS PALPATION APEX BEAT-FELT AT LEFT 5TH INTERCOSTAL SPACE


THRILLS PRESENT


NO PARASTERNAL HEAVES


AUSCULTATION


S1 AND S2 HEARD


RESPIRATORY SYSTEM


INSPECTION


DYSPNOEA PRESENT


SHAPE-ELLIPTICAL


B/L SYMMETRICAL


BOTH SIDES MOVING EQUALLY WITH RESPIRATION


NO SCARS, SINUSES, ENGORGED VEINS, PULSATIONS


PALPATION


TRACHEA-CENTRAL EXPANSION OF CHEST IS SYMMETRICAL


VOCAL FREMITUS-NORMAL PERCUSSION RESONANT BILATERALLY


AUSCULTATION:


BILATERALAIR ENTRY PRESENT


NORMAL VESICULAR BREATH SOUNDS PRESENT


CREPTS ARE HEARD


GCS EIVIM2


CENTRAL NERVOUS SYSTEM COMATOSE ON MECHANICAL VENTILATION SEDATED NO SIGNS OF MENINGEAL IRRITATION CRANIAL NERVES CANNOT BELICITED MOTOR SYSTEM-POWER CANNOT BE ELICITED TONE-NORMAL IN BILATERAL UPPER AND LOWER LIMBS SENSORY SYSTEM- CANNOT BE ELICITED REFLEXES


RT LT


B - -


T - -


S--


A--


K--


CEREBELLAR SIGNS CANNOT BE ELICITED


COURSE IN HOSPITAL


25 YEAR OLD MALE PRESENTED TO HOSPITAL WITH RTA TRAUMATIC BRAIN INJURY (20/03/23) WITH INTRA VENTRICULAR HEMORRHAGE (RESOLVED) WITH ASPIRATION


PNEUMONIA (RESOLVED), FRONTAL BONE FRACTURE S/P RIGHT FRONTAL LACERATION


WITH DEBRIDEMENT WAS DONE ON 21/03/23 HFMEF (EF 50%) SUDDEN CARDIAC ARREST


HIE ON MECHANICAL VENTILATION DAY 5 (25/03/23) POST CPR STATUS (2CYCLES) ON


25/03/23 PATIENT WAS EVALUATED CLINICALLY WITH APPROPRIATE INVESTIGATIONS


CONTINUED ON ACMV ON MY MRI BRAIN WAS DONE WHICH SHOWED FEATURES SUGGESTIVE OF SEVERE HYPOXEMIC BRAIN INJURY AND FEW ACUTE TO SUBACTUE


HEMATOMAS IN LEFT FRONTAL, MEDIAL, TEMPORAL AND LEFT LATERAL VENTRICLES


NEUROSURGEON OPINION WAS TAKEN IN VIEW OF SEVERE HYPOXEMIC BRAIN INJURY


AND ADVISED FOR TRACHEOSTOMY ON DAY 3 PATIENT HAD EPISODES OF MYOCLONIC JERKS. ANTIEPILEPTICS(VALPROATELEVIPIL)ICTMEASURED(3% NS, BROMOCRIPTINE) AFTER EXPLAINING THE ATTENDERS THE NEED FOR TRACHEOSTOMY AND WITH DUE CONSENT TRACHEOS TOMY WAS DONE ON 29/03/23 PATIENT HAD ANTERIOR WALL MI


PATIENT WAS ON IONOTROPE SUPPORT AND WEANED OFF BRAINSTEM REFLEXES INTACT PATIENT WAS WEANED OFF FROM VENTILATOR SUPPORT ON TO CPAP MODE AND


ON TO T PIECE PATIENT HAD INTERMITTENT HIGH GRADE FEVER SPIKES AND


DESATURATIONS, TREATED SYMPTOMATICALLY WITH ANTIPYRETICSCOLD SPONGINGS


T PIECE WAS REMOVED AND PATIENTS SATURATIONS IMPROVED ON ROOM AIR MINI BAL


PROCEDURE WAS PERFORMED IN VIEW OF VENTILATOR ASSOCIATED PNEUMONIA AND


REPORTS AWAITED PATIENT WAS DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION WITH BED CARE, TRACHEOSTOMY CARE AND PHYSIOTHERAPY EXPLAINED TO


ATTENDERS


NEUROLOGY OPINION WAS TAKEN AND ANTIEPILEPTICS WEANED OFF CONTINUED VALPROATE


REFERAL TO ANAESTHESIOLOGY ON 27/3/23


ADVICE


1 HEAD END ELEVATION AT 45

 2 IV FLUIDS AT 3% NS @70ML/HR 


3. ET TUBE ORAL AND RYLES TUBE SUCTIONING EVERY 4RTH HOURLY


4. INJ. PCM 100MLIVISOS IF TEMPERATURE 100F 5. EYE PROTECTION POSITION CHANGING FREQUENTLY


6. CONTINUE SEDATION @ 6ML/HR (IN FENTANYL 200MCGINJ, MIDAZOLAM 30MG+


INJ ATRACURIUM INFUSION)


7. REST CONTINUE TREATMENT AS PER PHYSICIAN ADVICE


8. GCS MONITORING


9CHEST PHYSIOTHERAPY


10. MAINTAIN NUTRITION


11 MONITOR BP PR SPO2, TEMPERATURE GRES 12. VENTILATOR SETTINGS MODE ACMV - VO, 7V 380ML RR 10-128PM, PEEP 5CM H20,


FI02-40%


REFERRAL TO OPTHALMOLOGY ON 26/05/23


IMPRESSION ON FUNDUS EXAMINATION NO FEATURES OF LOT NOTED


REFERRAL TO NEUROSURGERY ON 25/03/2023


ADVICE


1. INJ. MANNITOL 100ML IV/TID OR INF 3%NACL @20ML/HR


2INJ LEVERA 1GM/V/BD


3. INJ LACOSAMIDE 200MG IV/BD


4. REVIEW SOS


5. TAB CITICHOLINE 500 MG RT/BD


6.T DONEP-M RT/BD


7. TAMAN TAX 100MG RT/BD


8TAB BROMOCRIPTINE 2.5MG RT/BD


REFERRAL TO GENERAL SURGERY


GRADE 2 BED SORE


ADVICE


1. PNEUMATIC COMPRESSION BED


23RD HOURLY POSITION CHANGE OF PATIENT


3MS (WET,DRY) DRESSING



Investigation


BLOOD CULTURE- NO GROWTH SEEN


URINE CULTURE NO GROWTH SEEN


ET CULTURE- NO GROWTH SEEN


HEMOGRAM 26/3/23


HB-17 O GM/DL


TLC-13000CELLS/CU MM


N/L/E/M-57/28/5/10


PLATELET COUNT 3.62


7/4/2023 HB-10.3 GM/DL


TLC 10,000 CELLS/CUMM N/LE/M-54/30/4/12 PLATELET COUNT 307 LAKHS/CU MM


Treatment Given (Enter only Generic Name)


25/03/23


RYLES FEED 200ML MILK + 2 SCOOPS PROTEIN POWDER -4RTH HOURLY 100ML WATER-2


HOURLY


INJ NORADRENALINE 2AMP +46MLNS


INJ ATRACURIUM UNDILUTED-1ML/HR


INJ MIDRAZOLAM-SML/HR INJ.3% NS-20ML/HR


INJ LEVATIRACETRAM-16/IWBD INJ LACOSAMIDE200MG/V/ED


24/03/23


RYLES FEED 200ML MILK +2 SCOOPS PROTEIN POWDER -4RTH HOURLY, 100ML WATER-2


INJ NORADRENALINE 2AMP +46ML NS SMUHR INJ ATRACURIUM UNDILUTED SML/HR AMP+46MLNS


INJ MIDRAZOLAM-5ML/HR INJ.3% NS-20ML/HR


INJ LEVATIRACETRAM-1G/VBD INJ.LACOSAMIDE200MG/V/BO


EYE CARE FREQUENT POSITION CHANGE AIR BEDDING


BP PR RR SPO2 MONITORING HOURLY


GRBS MONITORING 2ND HOURLY


INJ LASIX 40MG/V/BD IV FLUID 0.9-50MLHR




27-03-23


RYLES FEED 200ML MILK + 2 SCOOPS PROTEIN POWDER -4RTH HOURLY 100ML WATER-2


HOURLY


INJ NORADRENALINE 2AMP +46MLNS 6ML/HR


INJ ATRACURIUM UNDILUTED-5ML/HR 1AMP+46ML NS


INJ 3% NS-20ML/HR


INJ MIDRAZOLAM-30MGHING FENTANYL200MCG+16ML NS 5ML/HR


INJ LEVATIRACETRAM-1C/V/BD


INJ LACOSAMIDE200MG/WBD


INJ LASIX 40MG/IV/BD


EYE CARE FREQUENT POSITION CHANGE AIR BEDDING


STRICT I/O CHARTING BP PR.RR.SPO2,MONITORING HOURLY GRBS MONITORING 2ND HOURLY


IV FLUID 0.9-50ML/HR


28/03/29


RYLES FEED 200ML MILK +2 SCOOPS PROTEIN POWDER WRTH HOURLY 100ML WATER-


HOURLY


IV FLUID NS-75MLHR


INJATRACURIUM UNDILUTED SMUHR AMP +46ML NS


INJ 9% NS-20MLHR


INJ MIDRAZOLAM-80MG+ING FENTANYL200MCG-16MLINS SMUHR


INJ LEVATIRACETRAM-1G/V/B0


INJ LACOSAMIDE200MG/V/BD


INJ LASIX 40MG/V/BQ


EYE CARE FREQUENT POSITION CHANGE AIR BEDDING


STRICTI/O CHARTING


BP PRRR SPO2 MONITORING HOURLY GRBS MONITORING 2ND HOURLY


INJ SODIUM VALPROATE 1GM IV STATFV8 500MG IV BD


29/03/23


RYLES FEED 200ML MILK +2 SCOOPS PROTEIN POWDER 4RTH HOURLY 100ML WATER -2 HOURLY



IV FLUID NS-75MLHR


INJ ATRACURIUM UNDILUTED 5ML/HR 11AMP+46ML NS


INJ.3% NS-20ML/HR


INJ MIDRAZOLAM-30MG+ING FENTANYL200MCG+16ML NS SML/HR


INJ LEVATIRACETRAM-1G/V/BD


INJ LACOSAMIDE200MG/V/BD


INJ SODIUM VALPROATE 1GM IVISTAT FB 500MG IV BD


INJ.CLEXANE 40MG IV/BD


INJ GLYCOPYROLATE 1MG IVISOS INJ NEOMOL 1MG IVISOS IF TEMPERATURE MORE THAN 101F


EYE CARE FREQUENT POSITION CHANGE AIR BEDDING


STRICT I/O CHARTING


BP PR RR SPO2,MONITORING HOURLY GRBS MONITORING 2ND HOURLY


30/03/23


RYLES FEED 200ML MILK + 2 SCOOPS PROTEIN POWDER-ARTH HOURLY 100ML WATER-2


HOURLY


IV FLUID NS-75MLHR


INJ SODIUM VALPROATE 1GM IV STAT FB 500MG IMBD


INJ.CLEXANE 40MG IV/BD


INJ GLYCOPYROLATE IMG MISOS


INJ NEOMOL TMG IVISOS IF TEMPERATURE MORE THAN 1016


EYE CARE FREQUENT POSITION CHANGE AIR BEDDING


STRICT IO CHARTING


BP PRRR SPO2 MONITORING HOURLY


GRBS MONITORING 2ND HOURLY


31/03/23


RYLES FEED 200ML MILK +2 SCOOPS PROTEIN POWDER-4RTH HOURLY, 100ML WATER 2


HOURLY


IV FLUID NS-75MLHR


INJ SODIUM VALPROATE 1GM IV STAT FB 500MG IV BD


INJ CLEXANE 40MG IVBD


INJ GLYCOPYROLATE IMGIVISOS


INJ 3 NS-10MLHR


INJ NEOMOL IMG IV/SOS IF TEMPERATURE MORE THAN 101F


TPCM 650MG RT/SQS


EYE CARE FREQUENT POSITION CHANGE AIR BEDDING


STRICT TO CHARTING


BP PR RR SPO2 MONITORING HOURLY GRBS MONITORING 2ND HOURLY


1/4/23


RYLES FEED 200ML MILK +2 SCOOPS PROTEIN POWDER 4RTH HOURLY, 100ML WATER-2


HOURLY


VFLUID NS-125MUHR


INJ SODIUM VALPROATE IGM IV STAT FB 500MG IV BD


INJ CLEXANE 40MG IV/BD


INJ 3 NS-5MLHR


INJ NEOMOL 1MG IV/SOS IF TEMPERATURE MORE THAN 101F


TPCM 650MG RT/SOS


EYE CARE FREQUENT POSITION CHANGE AIR BEDDING


STRICT VO CHARTING


BP PRRR SPO2 MONITORING HOURLY GRBS MONITORING 2ND HOURLY


INJ PIPTAZA 5GM IV/STAT


2/4/23


RYLES FEED 200ML MILK +2 SCOOPS PROTEIN POWDER -4RTH HOURLY 100ML WATER-2


HOURLY


IV FLUID NS-100ML/HR


INJ SODIUM VALPROATE 1GM IV STAT FB 500MG IV BD INJ CLEXANE 40MG IV/BD


INJ 3 NS-5MLHR


INJ NEOMOL 1MG IVISOS IF TEMPERATURE MORE THAN 101F


TPCM 650MG RT/SOS


INJ PIPTAZA 5GM IV/STAT


EYE CARE FREQUENT POSITION CHANGE AIR BEDDING


THE STRICT I/O CHARTING


BP.PR RR SPO2 MONITORING HOURLY GRBS MONITORING 2ND HOURLY


TEMPERATURE MONITORING 2ND HOURLY


NEOSPORIN POWDER AND BED SORE DRESSING


INJ KCL 2 AMPULES IN 500ML NS IV/STAT OVER SHRS ET TUBE ORAL TUBE


LUBREX EYE DROPS/TID


NEBWITH IPRAVENT 4TH HOURLY INJ GLYCOPYROLATE IMG IV/SOS


CHEST PHYSIOTHERAPY


UPPER LIME LOWER LIMB PHYSIOTHERAPHY


4/4/23


RYLES FEED, 200ML WATER 4 HOURLY 200ML MILK +2 SCOOPS PROTEIN POWDER -4RTH HOURLY IV FLUID NS-125ML/HR


INJ SODIUM VALPROATE 1GM IV 80 INJ PIPTAZ 4.5 GM IV/TID


INJ CLEXANE 40MG SC/BD


INJ NEOMOL 1MG IV/SOS IF TEMPERATURE MORE THAN 101F


T PCM 650MG RT/SOS


INJ GLYCOPYRROLATE 1 MGIVISOS


SYP POTKLOR 15 MLRT/TID


NEOSPORIN POWDER AND BED SORE DRESSING


HOURLY SUCTIONING


EYE CARE FREQUENT POSITION CHANGE AIR BEDDING


STRICT I/O CHARTING


BP PRRR SPO2 MONITORING HOURLY


GRBS MONITORING 2ND HOURLY


TEMPERATURE MONITORING 2ND HOURLY


NEB WITH IPRAVENT4TH HOURLY


TAB CITICHOLINE 500 MG RT/B0


T DONEP-M RTBD


TAMAN TAX 100MG RT/B0 TAB BROMOCRIPTINE 2.5MG RT/BD


CHEST PHYSIOTHERAPY UPPER LIMB LOWER LIMB PHYSIOTHERAPHY


5/4/23


RYLES FEED, 200ML WATER 4 HOURLY 200ML MILK +2 SCOOPS PROTEIN POWDER -4RTH


INJ GLYCOPYRROLATE 1 MGIVISOS


SYP POTKLOR 15 MLRT/TID


NEOSPORIN POWDER AND BED SORE DRESSING


HOURLY SUCTIONING


EYE CARE FREQUENT POSITION CHANGE AIR BEDDING


STRICT I/O CHARTING


BP PRRR SPO2 MONITORING HOURLY


GRBS MONITORING 2ND HOURLY


TEMPERATURE MONITORING 2ND HOURLY


NEB WITH IPRAVENT4TH HOURLY


TAB CITICHOLINE 500 MG RT/B0


T DONEP-M RTBD


TAMAN TAX 100MG RT/B0 TAB BROMOCRIPTINE 2.5MG RT/BD


CHEST PHYSIOTHERAPY UPPER LIMB LOWER LIMB PHYSIOTHERAPHY


5/4/23


RYLES FEED, 200ML WATER 4 HOURLY 200ML MILK +2 SCOOPS PROTEIN POWDER -4RTH hourly


IV FLUID NS-125ML/HR


HOURLY


INJ SODIUM VALPROATE 1GM IV BD INJ PIPTAZ 45 GM IV/TID


INJ CLEXANE 40MG SC/BD


INJ NEOMOL 1MG IV/SCS IF TEMPERATURE MORE THAN 101F


T PCM 650MG RT/SOS


INJ GLYCOPYRROLATE 1 MGIV/SOS


SYP POTKLOR 15 MLRT/TID


NEOSPORIN POWDER AND BED SORE DRESSING


HOURLY SUCTIONING


EYE CARE FREQUENT POSITION CHANGE AIR BEDDING


STRICT I/O CHARTING


BP PRRR SPO2,MONITORING HOURLY


GRBS MONITORING 2ND HOURLY


TEMPERATURE MONITORING 2ND HOURLY


NEB WITH IPRAVENT 4TH HOURLY


TAB CITICHOLINE 500 MG RT/BD


DONEP-M RT/BD


TAMANTAX 100MG RT/BD


TAB BROMOCRIPTINE 2.5MG RT/BD


CHEST PHYSIOTHERAPY


UPPER LIMB LOWER LIMB PHYSIOTHERAPHY


6/4/23


RYLES FEED200ML WATER -2 HOURLY 200ML MILK +2 SCOOPS PROTEIN POWDER-4TH


HOURLY


IV FLUID NS-125ML/HR


INJ SODIUM VALPROATE 1GM IV BD


INJ PIPTAZ 45 GM VTID


INJ CLEXANE 40MG SC/BD


INJ NEOMOL 1MG IVISOS IF TEMPERATURE MORE THAN 101F


T PCM 650MG RT/SOS


INJ GLYCOPYRROLATE 1 MG IV/SOS


SYP POTKLOR 15 MLRT/TID


TCITICHOLINE 500MG RT/BD


T DONEP-MRTBD


TAMANTAX 100MG RT/BD


NEBULISATION WITH IPRAVENT


NEOSPORIN POWDER AND BED SORE DRESSING


HOURLY SUCTIONING


EYE CARE FREQUENT POSITION CHANGE AIR BEDDING STRICT VO CHARTING


BP PR RR SPO2 MONITORING HOURLY


GRBS MONITORING 2ND HOURLY


TEMPERATURE MONITORING 2ND HOURLY TAB BROMOCRIPTINE 2.5MG RT/BD


CHEST PHYSIOTHERAPY


UPPER UMB LOWER LIMB PHYSIOTHERAPHY


7/4/23


RYLES FEED, 200ML WATER -2 HOURLY 200ML MILK +2 SCOOPS PROTEIN POWDER TH


HOURLY


IV FLUID NS-125ML/HR


INJ SODIUM VALPROATE 1GM IV BD


INJ CLEXANE 40MG SC/B0


INJ NEOMOL IMG IV/SOS IF TEMPERATURE MORE THAN 101F


T PCM 650MG RT/SOS


INJ GLYCOPYRROLATE 1 MG IWSOS


SYP POTKLOR 15 MLRT/TID


TPCM 650MG RT/SOS


INJ GLYCOPYRROLATE 1 MG MSOS


SVP POTKLOR 15 MLRT/TID


TCITICHOLINE 500MG RT/BD


TDONEP-M RTBD TAMAN TAX 100MG RT/BD


NEBUUSATION WITH IPRAVENT, MUCOMIST 4TH HOURLY


NEOSPORIN POWDER AND BED SORE DRESSING


HOURLY SUCTIONING


EYE CARE FREQUENT POSITION CHANGE AIR BEDDING


STRICT VO CHARTING


BP PRRR SPO2 MONITORING HOURLY


GRES MONITORING 2ND HOURLY TEMPERATURE MONITORING 2ND HOURLY


TAB BROMOCRIPTINE 2.5MG RT/BD


CHEST PHYSIOTHERAPY


UPPER LIMB LOWER UMB PHYSIOTHERAPHY


Advice at Discharge


RYLES FEED200ML WATER 4 HOURLY 200ML MILK +2 SCOOPS PROTEIN POWDER - 4TH


HOURLY


SODIUM VALPROATE 1GM PO BD TILL ADVICED TO STOP


T.PCM 650MG RT/SOS


TAB CITICHOLINE 500 MG RT/BD


T DONEP-M RT/BD


TAMANTAX 100MG RT/BD


NEOSPORIN POWDER AND BED SORE DRESSING


HOURLY SUCTIONING


EYE CARE FREQUENT POSITION CHANGE AIR BEDDING


NEB WITH MUCOMIST 4TH HOURLYIPRAVENT 6TH HOURLY


CHEST PHYSIOTHERAPY


UPPER LIMB LOWER UMB PHYSIOTHERAPHY

Comments

Popular posts from this blog

An 82 year old man with pain in neck, lower back, right knee and tingling sensation in right arm

  This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  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.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome. This is a case of an 82 year old man with pain in the neck, lower back, right knee and tingling sensation in his right arm. History of Presenting Illness: Patient was apparently asymptomatic 10 years ago until he developed shortness of breath of grade 2. It has been occurring intermittently over the past 10 years. No history of Orthopnea or pnd Until 5 years ago he says he had a relatively normal life and ran his own barber business for over 60 years. About 6 years ag

“MY EXPERIENCES WITH GENERAL CELLULAR AND NEURAL CELLULAR PATHOLOGY IN A CASE BASED BLENDED LEARNING ECOSYSTEM'S CBBLE "

  Hello and welcome! My name is Bhargavi Kantipudi and i am a medical student from india. One of the most transformative experiences for medical students is patient case based learning, which offers a unique perspective in real world medical scenarios. I would like to present a selection of medical cases that i have examined. CBBLE PAJR PARTICIPATORY LEARNING ACTION RESEARCH DISCLAIMER  NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS/HER GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT We began our clinical rotations in 2nd year and in our initial days of medicine postings, I remember going to the ward a few times. I can recall a few patients, an old women with dysphasia, a man with tremors and bradykinesi

45 Year Male with Pain Abdomen

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. 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. This is a case of a 45 year old male, carpenter by occupation came to OPD with chief complaints of: 1. Constipation since 3 days 2. Pain in abdomen since 2days 3. Vomitings since 2 days. HISTORY OF PRESENTING I