2. A 64 years male patient was admitted to the hospital with

Chief complaints:
one episode of syncope,
loss of memory ocassinally
muscle weakness,
altered breathing and heart rate.

Past medical history:
type -II diabetes mellitus ( from past 3yrs)

Social history:

ONGOING EXAMINATIONS:
smoker, alcohol consumer
Investigation
Observed value
Normal value
B.P
130/80 mmHg
120/80mmHg
P.R
110/min
72/min
TEMP
98.4F
98.3F

3. 
LBORATORY INVESTIGATIONS:
HAEMATOLOGY
Investigation
Observed value
Normal value
Hb
13.6gm%
12-16gm%
RBC
4.8micells/cumm
3.5-4.5micel/cumm
WBC
7700cells/cumm
4000-11000c/cumm
PLATELETS
1.8LAK
2-3LAK
DIFFERENTIAL COUNT
Investigation
Observed value
Normal value
Polymorphs
55%
40-75%
Lymphocytes
38%
20-45%
Eosinophils
5%
1-6%

4. biochemistry
Investigation
Observed value
Normal value
R.B.S
282mmol/L
135-145mmol/L
F.B.S
155mg/dl
75-100mg/dl
Urine examination
Investigation
Normal value
PH
5.2
5-80
Specfic gravity
1.010
1.010-1.030
Urine sugar
Nill
Nill
u.Albumin

Observed value
Nill
nill
CT SCAN and MRI SCAN were done

5. (White areas indicate
hyperdensity = blood)
Large left frontal
intracerebral hemorrhage.
Intraventricular bleeding
is also present
No fibrinolytics!

6. 
DIAGNNOSIS :

TREATMENT:
CEREBRO VASCULAR ACCIDENT
DIABETES MELLITUS
GENERIC
NAME
BRAND
NAME
DOSE
FREQUENCY ROUTE OF
ADM.
Pantaprazole
Inj.pantop
40mg
OD
IV
Ondansetron
Inj.periset
8mg
S0S
IV
Aspirin
Tab.dispirin
350mg
OD
IV
Atorvastatin
Tab.storvas
40 mg
H2S
ORAL
Piracetam
Tab.nootro PR 120mg
TID
ORAL
Valproic acid
Tab.somazina
500mg
BD
IV
Insulin
Inj.insugen
10units
BD
IV

7. SOAP analysis:
Problem 1:
Cerebro vascular accident
subject:
chief complaints of one episode of syncope,
loss of memory , weakness.
CVA conformation done by MRI scan report (hemorrhage)
object:
assessment:
- For reducing the cerebro cortical insufficiency ,neurotonics was
prescribed.
- For reducing the depression, Antiepileptic drug was prescribed.
-For reducing the hemorrhagic condition, antiplatelet drug was
prescribed.
Plan:
Tab.piracetam-120mg thrice daily.
Tab.valproic acid-500mg twice daily.
Tab.dispirin- 350mg once daily.

8. Problem 2:
Diabetes mellitus
Subject: patient with known case of diabetes mellitus from past 3yrs.
Object:
the abnormal lab. Reports found to be
Investigation
Observed value
Normal value
F.B.S
155mg/dl
75-100mg/dl
R.B.S
282mg/dl
135-145mg/dl
Assessment: for reducing the blood sugar levels insulin was prescribed.
Plan:
Inj.insugen-10 units twice daily.