A 60 yr old male with vomiting since 15 days after a known head trauma
1st December 2021
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Khushi Tulsyan
Roll no. 75
A 60 yr old male presented with chief complaints of vomiting since 15 days
A 60 yr old male, farmer by occupation presented to OPD with chief complaints of recurrent episodes of vomiting after every meal since 15 days.
History of presenting illness:
Patient was apparently asymptomatic 15 days ago and then he started to vomit after every meal precedded by headache and mild giddiness and heat sensation on forhead.
Not associated with pain abdomen, loose stools, fever, cough.
Patient complainted of giddiness followed by vomiting for 10-15 mins.
Past history:
He had a history of trauma on scalp 4 months back which was followed by swelling and bleeding which stopped within some time after the application of ice pack.
He had an history of fight 2 months back due to which he was injured on left temporal area.
He visited a RMP and was advised to take anti hypertensives which he took for 2 days and then stopped.
History of repeated vomiting from 15 days because of which patient became very weak and was not able to walk and the relatives themselves kept a catheter 15 days back for their conveniece.
Not a known case of hypertension/diabetes/thyroid /tuberculosis/epilepsy/asthma
Personal history:
Appetite is normal
Mixed diet
Sleep is adequate
Bowel and bladder movements are normal
Allergies : He had an history of allergic reaction on upper gluteal region which subsided within 4-5 days after applying the ointment prescribed by RMP. He had this same episode of allergic reaction since 1 year for 4 times.
Patinet is a chronic smoker with 20 beedis/day since 40 yrs and stopped since 15 days.
Physical Examination:
General:
The patient was examined in well lit room after taking his consent.
Patient is conscious ,coherent and cooperative
Patient is well oriented to time and place
Moderately built and moderately nourished
Pallor: Present
Icterus: absent
Clubbing:absent
Cyanosis:absent
Lymphadenopathy: absent
Edema: absent
VITALS
Temperature: afebrile
Pulse:62 bpm
Respiratory rate: 18cpm
Blood pressure: 160/100 mm Hg
SpO2 at room air: 98%
GRBS:147mg/dl
SYSTEMIC EXAMINATION
Cardiovascular system:
S1 and S2 heard ,no murmurs
Respiratory system:
Central position of trachea
Vesicular breath sounds
No wheeze,no dyspnoea
Abdomen:
Scaphoid shape
No tenderness
No palpable masses
Bowel sounds present
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
Provisional Diagnosis : Subdural Heamtoma
Investigations:
1.Hemogram:
Hemogram done on day of submission
Hb reduced
Hb reduced
2. Complete Urine Examination
Urine examinations results are normal
3. Serum electrolytes
Sodium levels are slightly elevated
Chloride levels are slightly reduced
4. Crp
5. Hormonal Assay
6. ECG
7. 2D Echo
8. CT scan
Hyperdense - banana shaped indicating subdural hemorrhage
Treatment:
Inj Optineuron 1 amp in 100 NS/IV/OD
Inj Zofer 4 mg IV / TD
Tab Pan 40 mg PO /OD
Bp/Temp/Pr monitoring 4th hourly
Tab Ondasetron chewable tablets / TD
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