This case presentation summarizes a 51-year-old male patient admitted to the hospital for slurred speech, headache, and facial puffiness. The patient has a history of type 2 diabetes, bronchial asthma, and hypertension. Physical exams and lab results indicated elevated potassium, uric acid, and inflammatory markers. A CT scan showed evidence of old cerebral infarcts. The patient was diagnosed with asthma exacerbation. The treatment plan included medications to control inflammation, blood pressure, cholesterol, and blood sugar. Upon discharge, the patient was counseled on asthma management and medication compliance.
2. DEMORGRAPHIC DETAILS OF THE
PATIENT
• NAME : M Ramachandra
• Age : 51 years
• Sex : Male
• DOA : 14/9/22
• DOD : 16/9/22
• Ward : General medicine ward
• I.P No : 202253628
3. REASON FOR ADMISSION
• C/O Slurring of speech since 1 day , headache ,facial
puffiness x 15 days back .
PAST MEDICAL HISTORY
T2 DM Bronchial asthma , HTN .
PAST MEDICATION HISTORY
Poor compliance with treatment and an irregular medication
.
7. RENAL FUNCTLION TESTS
Urea/BUN 14 mg/dL 10-15 mg/dL
Uric acid 7.4 mg/dL 2.5-7.0 mg/dL
Sr. Creatinine 1.3 mg/dL 0.9-1.4 mg/dL
LIVER FUNTION TEST AND ENZYMES
SGOT/AST 35 <40
ALT 15 <40
Albumin 3.6 mg/dL 3.5-5.5 mg/dL
bilirubin total 1.1 mg/dL 0.2-1.0 mg/dL
total protein 6.8 6.8
8. OTHER INVESTIGATION
• CT Scan brain is bilateral front parietal , subdural
hygromic
Right basal ganglia old intract with (c) glosis.
DIAGONINS
T2 DM Since bronchial asthma since systemic HTN , CVA
old infranct since acclerated hypertension , brocoin aphasia
.
9. SOAP ANALYSIS
SUBJECTIVE EVIDENCE
C/O Slurring of speech since 1 day headache , facial
puffiness x 15 days back .
OBJECTIVE EVIDENCE
• Basophills : 0.02 %
• Esinophills : 0.58 %
• k+ : 5.7 mg/dL
• uric acid : 7.4 mg/dL
10. GOALS OF THERPY
• To reduce slurring of speech .
• To reduce headache and puffiness.
DISEASES SPECIFIC
To bring basophills , einophills , monocytes , k+ and uric
acid to the normal level .
ASSESMENT
Based on subjective and objective evidence the case is assesed
as
ASTHMA .
11. PLANNING
T.Name (ROA and frequency) G. Name Dose
T. aspirin (PO) 0-1-0 Aspirin 75mg
T. Atrova 0-0-1 Atrovastatin 20mg
Inj. panto 1-0-0 Pantoprazole 40mg
Inj. labetelol A 1-0-1 Labetelol
Inj. plain insulin
T. amlog (PO) 1-0-0 Amlodipine
Nebulization Budecort
Inj. Cefriazone (UV) 1-0-1 Cefriazone
koracort inhaler 2-0-2
T. Clopin (PO) 0-1-0 Clopilogrel
12. MONITORING PARAMETER
• Aspirin (antiplatelet)
prevent blood cells called platelets from clumping together to form a clots .
• T. Atorva (statin)
Inhibite HMG Co . decrease cholestrol production in the liver .
• Inj. Panto (proton pump inhibitor)
Used to decrease the acid in the stomach .
• Inj. Labetelol (beta - blocker)
Acts by blocking alpha and beta adrenergic receptor ,resulting in decrease peripheral vascular
resistence .
13. • Inj. Plain insulin
It is short acting insulin . it works by helping blood sugar (glucose) get into cells so body can use
it for energy.
• T. Amlog (P.O) (CCB)
Inhibite the transmembrane influx of calcium ions into vascular smooth muscle and cardiac
muscle .
• Inj. Cefriazone (Antibiotics)
It works by killing bacteria or preventing their growth.
• T. Cloidogrel (Antiplatelets)
It works by preventing platelets from collecting and forming clots .
14. DISCHARGE MEDICATION
Brand name Generic name Dose and Days
T.Amlog Amlodipine 5mg 1-0-0
T . B Complex B complex 0-1-0
T . Aspirin Aspirin 75mg 0-1-0
T . Atorva Atorvastatin 100mg 1-0-0
Forcost inhales 2 puffs
15. PATIENT COUNSELLING
• A. DISEASES : Asthma is a chronic inflammatory disorder
of the airways causing air flow obstruction and recurrent
episodes of wheezing , breathlessness , chest tightness
and coughing .
• B . MEDICATION : B complex should taken on an empty
stomach 1 hour before or 2 hours after meals . Take with
a full glass of water .
• C. LIFESTYLE : Reduce exposure to indoor allergens .
