04-06-2025
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE E DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[04-06-2025 21.35] PPM 1: Same patient with basal ganglia Hemorrhagic infarct. His mother was also our patient of Diabetes and her foot ulcer still hasn't healed in the last 4 months.
[04-06-2025 21.58] PPM 1: MRI and CT scan videos of the patient. 👇
[04-06-2025 22:07] PPM 1: https://youtube.com/shorts/3OZEn00dlRM?si=OYtXvHAYy_UX2ml-
[04-06-2025 22:08] PPM 1: https://youtu.be/jnKGMpmBwQQ?si=2b-HUmbAxxtSILzL
[04-06-2025 22:09] PPM 1: https://youtu.be/PbULZ_Srlmw?si=cLnyklRpcPoH8_5u
[04-06-2025 22.10] PPM 1: His mother was also our patient of Diabetes and her foot ulcer still hasn't healed in the last 4 months. 👇
Age/Gender: 28 Years/Male
Address:
Discharge Type: Relieved
Admission Date: 31/05/2025 10:25 AM
MLC No
28658
Name of Treating Faculty
(ASST PROF)
(SR)
(PGY3)
(PGY2)
(PGY1)
Diagnosis
RTA (HEAD INJURY)
INTRAPARENCHYMAL BLEED IN THE LT BASAL GANGLIA
ACUTE INFARCT IN THE ANT BODY OF CAUDATE NUCLEUS.
Case History and Clinical Findings
CHIEF COMPLAINTS
PT WAS BROUGHT TO CASUALTY WITH A/H/O RTA 3 DAYS BACK C/O PAIN OVER RT EYE
AND PAIN OVER RT AND LT CHEEK SINCE 3 DAYS.
HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS BACK THEN PATIENT HAD A
A/H/O RTA 3 DAYS BACK SLIP AND FALL FROM BIKE AND WENT TO LOCAL GOVT HOSPITAL ONGOLE WHERE PRIMARY TREATMENT WAS DONE.AT THE TIME OF FALL HE HAD LOSS OF CONSCIOUSNESS FOR 1 HR AND REGAINED CONSCIOUSNESS AFTER 52 HOURS IN THE HOSPITAL.
PRESENT ILLNESS:
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KIMS HOSPITALS
PATIENT C/O PAIN OVER RT EYE AND RT AND LT CHEEK .NO H/O FEVER, VOMITINGS, SOB, CHEST PAIN, CHEST HEAVINESS, NO H/O ABD PAIN, IRREGULAR
BOWEL AND BLADDER HABITS.NO H/O INVOLUNTARY MOVEMENTS, DIFFICULTY IN
SWALLOWING, READING, WRITING, LOSS OF APPETITE, WEIGHT LOSS, LOSS OF MEMORY.
HISTORY OF PAST ILLNESS:
NO H/O SIMILAR COMPLAINTS IN THE PAST
NOT A K/C/O HTN, T2DM, ASTHMA, COPD, EPILLEPY, CAD, CVA, TB, HTN.
TREATMENT HISTORY: NO SIGNIFICANT TREATMENT HISTORY
PERSONAL HISTORY: DIET- MIXED, APPETITE:
NORMAL, SLEEP: ADEQUATE, BOWEL BLADDER: REGULAR,
ADDICTIONS- OCCASIONALLY ALCOHOLIC- SINCE 10 YEARS, STOPPED 4 YEARS AGO GENERAL EXAMINATION:NO PALOR ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA BP:130/80 MMHG, PR: 54/MIN, TEMP: AFEBRILE, RR:17/MN, SPO2:96%, GRBS:114MG/DL
SYSTEMIC EXAMINATION:CVS, CNS, RS, PA NORMAL
COURSE IN THE HOSPITAL: A 29YR OLD MALE CAME TO CASUALTY WITH H/O RTA 3 DAYS BACK A/W C/O PAIN OVER RT EYE AND PAIN OVER RT AND LT CHEEK SINCE 3 DAYS. PATIENT WAS EVALUATED CLINICALLY AND APPROPRIATE
INVESTIGATIONS WERE DONE WAS TREATED WITH IVF NS, RL-@100ML/HR, IVF 3%NACL
@15ML/HR, IV CONTINUOS INFUSION, INJ MONOCEF 1G IV/BD, INJ PAN 40MG IV/OD, INJ
LEVIPIL 500MG IV/BD IN 100 ML NS OVER 30 MIN, E/D MOXIFLOX 6E/D 1 WEEK, E/D LUBREX 6E/DAY 1 WEEK, TAB.CHYMORAL 40 PO/BD 5 DAYS, OINT T BACT THRICE DAILY AT SUTURE SITES, OINT CIPLOX BD(L/A), HEAD END ELEVATION @45 DEGREE.PATIENT WAS REFERRED TO OMFS ON 31-5-25 AND PRIMARY SUTURING WAS DONE UNDER LA.PATIENT WAS REFERRED TO OPHTHALMOLOGY DEPT ON 31-5-25 I/V/O LACERATION BELOW RT EYE, HE WAS REFERRED TO NEUROSURGERY ON 31-5-25 I/V/O BLEED IN BASL GANGLION, NO ACTIVE INTERVENTION IS ADVISED. MRI SCAN WAS DONE ON 2-6-25 IMPRESSION GIVEN WAS ACUTE TO EARLY SUBACTUE HEMORRHAGE WITH MODERATE SORROUNDING VASOGENIC EDEMA IN THE LT BASAL GANGLIA MEASURING APPROX 20 * 12 MM. CT SCAN WAS DONE ON 31-5-25 AND IMPRESSION WAS ACUTE INTRAPARENCHYMAL HEMORRHAGE MEASURING APPROX 2*1.3CM SMALL HYPODENSE AREAS MEASURING APPROX 1.7*1.1 WAS OBSERVED. SEGMENTAL DEPRESSED FRACTURES IN THE RT ZYGOMATIC ARCH. PATIENT WAS REFERRED TO NEUROLOGY ON 5/6/25 ADVISED TO START ANTIPLATELET AND FOLLOW UP IF REQUERIED AND ADVICED HE CAN BE TAKEN FOR HIGH RISK SURGERY FOR
OMFS DEPARTMENT.
Investigation
Anti HCV Antibodies - RAPID 31-05-2025 Non Reactive
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KIMS HOSPITALS
HBsAg-RAPID 31-05-2025 Negative RFT 3-06-2025, UREA 22 mg/dl, CREATININE 0.9 mg/dl,, URIC ACID 3.4 mmol/L, CALCIUM 9.8 mg/dl, PHOSPHOROUS 4.2 mg/dl, SODIUM 138 mmol/L, POTASSIUM 4.4 mmol/L, CHLORIDE 105 mmol/L
LIVER FUNCTION TEST (LFT) 31-05-2025Total Bilurubin 1.36 mg/dL, Direct Bilurubin 0.31
mg/dl, SGOT(AST) 20 IU/L, SGPT(ALT) 21 IU/L, ALKALINE PHOSPHATASE 141 IU/L, TOTAL
PROTEINS 6.1 gm/dl, ALBUMIN 3.89 gm/dl, A/G RATIO 1.76
COMPLETE BLOOD PICTURE (CBP)
1-06-2025 HAEMOGLOBIN 14.5 gm/dl, TOTAL COUNT 8000 cells/cumm, NEUTROPHILS 57
,LYMPHOCYTES 33 %, EOSINOPHILS 02 % , MONOCYTES 08 %, BASOPHILS 00 %
PLATELET COUNT 2.76SMEAR Normocytic normochromic
blood urea 21mg/dl
serum electrolytes sodium 136mmol/l potassium 4.2mmol/l chloride 101mmol/l calcium ionized
120mmol/l
CT, MRII SCAN WAS DONE ON 2-6-25 IMPRESSION GIVEN WAS ACUTE TO EARLY SUBACTUE HEMORRHAGE WITH MODERATE SORROUNDING VASOGENIC EDEMA IN THE LT BASAL GANGLIA MEASURING APPROX 20 * 12 MM. CT SCAN WAS DONE ON 31-5-25 AND IMPRESSION WAS ACUTE INTRAPARENCHYMAL HEMORRHAGE MEASURING APPROX 2*1.3CMSMALL HYPODENSE AREAS MEASURING APPROX 1.7*1.1 WAS OBSERVED.
SEGMENTAL DEPRESSED FRACTURES IN THE RT ZYGOMATIC ARCH.
Treatment Given (Enter only Generic Name)
IVF NS, RL @100MLL/HR
IVF3% NACL@15ML/HR
IV CONTINUOUS INFUSION
INJ MONOCEF 1GM/IV/BD
INJ MONOCEF IGM/IV/BD
INJ PAN 40MG IV/OD
INJ LEVIPIL 500MG/IV/BD IN 100ML NS OVER 30MIN
E/D MOXIFLOX 65/DAY 1WEEK
E/D LUBREX-6E/DAY 1WEEK
TAB CHYMORAL FORTE PO/BD 5 DAYS
OINT T BACT THRICE DAILY AT SUTURE SITE
OINT CIPLOX BD(L/A)
Advice at Discharge
TAB PCM 650MG TID FOR 3DAYS
TAB CHYMORAL FORTE PO/BD 5 DAYS
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KIMS HOSPITALS
TAB MVT OD 10 DAYS
T.CLAVUM 625MG PO/BD 5DAYS
T.METROGYL 400MG PO/TID 5DAYS
Follow Up
REVIEW NEURO OP ON THURSDAY
REVIEW DENTAL [OMFS] OP ON SATURDAY
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:
For Treatment Enquiries Patient/Attendent Declaration: - The medicines prescribed
and the advice regarding preventive aspects of care, when and how to obtain urgent care have been
explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date
Date:5-6-25
Ward: GM
Unit: 6
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