SUBJECTIVEOBJECTIVEASSESSMENTPLANPATIENT EDUCATION

PROBLEM

1.VITAL SIGNS2.LAB TESTS3.MED.LIST

ETIOLOGY OF PROBLEM

1.EVALUATE CURRENT THERAPY FOR PROBLEM2.EVALUATE NEED FOR THERAPY

GOALS FOR TREATMENT OF PROBLEM

RECOMMEND1. DRUG TREATMENT FOR PROBLEM2. MONITORING PARAMETERS FOR EACH DRUG LISTED3. FURTHER TESTS FOR PROBLEM IF NEEDED4. DRUGS TO BE AVOIDED AND WHY

A male patient of 18 years old was admitted in a MICU ward.C/O: Alleged H/O RTA , head injury .Lacerated injury on left side of forehead around 5*1.5cm. PMH: Non- remarkable prior to admission.

Vitals:PR -82/minBP- 110/80mmHgSPO2-98%Temp-98.4FCurrent medication:INJ . Piracetam 12gms BDwith 500mlNSINJ.Citicoline 500mg BDINJ . Mannitol 20% BDInj. Phenytoin 100mg TDSInj. Pantaprazole 40mg ODINJ. Ondansetron 4mg ODINJ. Meropan em 1gmBDINJ.Primaxin 1gm BDSubdural hematoma is usually caused by a head injury such as from a fall , motar vehicle collision , or an assault

1.the current therapy is to stop bleeding in the sub dural space of brain and prevent further damage to the brain.2. the required therapy for sub dural hemorrhage is to prevent the bleeding in the sub dural space of brain .The goal of treatment is to control symptoms and reduce or prevent permanent damage to the brain.1. INJ . Piracetam 12gms BDwith 500mlNS INJ.Citicoline 500mg BDINJ . Mannitol 20% BDInj. Phenytoin 100mg TDSInj. Pantaprazole 40mg ODINJ. Ondansetron 4mg ODINJ. Meropan em 1gmBDINJ.Primaxin 1gm BD2.*parameters to be monitored in case of mannitol include intracranial pressure and cerebral blood flow using laser Doppler flow metry, mitochondrial NADH redox state by the fluro metric technic.*phenytoin admimistration should need to monitorthe parameters of cardiovascular system because of the risk of severe hypertension and cardiac arrhythmias.*cardiac monitoring and blood pressure monitoring should be done while using pantoprazole.

3. .MRI should done if needed.4. anti coagulants should be avoided because it worsen the hemorrhage.1.Always use safety equipment at work and play to reduce your risk of a head injury .2.Advice the patient on taking medication.3.Phenytoin levels may decrease when the suspension is given with enteral feedings. This could lead to a loss of seizure control. You could interrupt the feeding for 2 hours before and after the phenytoin dose.