Case No.

:
Date:
SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLAN

PATIENT
EDUCATION

PROBLEM

1.VITAL SIGNS
2.LAB TESTS
3.MED.LIST

ETIOLOGY OF PROBLEM

1.EVALUATE CURRENT
THERAPY FOR
PROBLEM
2.EVALUATE NEED FOR
THERAPY

GOALS FOR
TREATMENT OF
PROBLEM

SUB-DURAL

Vitals:

A subdural hematoma is

1. In small subdural

The

HEMATOMA

PR

- 82/min

a collection of blood

hematomas with mild

treatment

BP

- 110/80 mmHg

outside the brain.

symptoms, doctors may

control

goal
is

RECOMMEND
1. DRUG TREATMENT FOR
PROBLEM
2. MONITORING
PARAMETERS FOR EACH
DRUG LISTED
3. FURTHER TESTS FOR
PROBLEM IF NEEDED
4. DRUGS TO BE AVOIDED
AND WHY
of
1. 1. The medication Mannitol to

1.Always use safety

to help reduce swelling or

equipment at work and

symptoms pressure in the brain.

18 y/o male patient

SPO2 - 98 %

Subdural hematomas

recommend no specific

and

was admitted in a

Temp- 98.4 F

are usually caused by

treatment other than

prevent permanent

2.Advice the patient on

severe head injuries. The

observation. Repeated

damage

taking medication.

Radiology

bleeding and increased

head imaging tests are

brain.

CT Scan: Small

pressure on the brain

Subdural Hematoma

MICU ward.
C/O:
Alleged H/O RTA,
head injury. Lacerated
injury on left side of

reduce
to

or Phenytoin to control seizures

play to reduce your risk

the 2. Parameters to be monitored

of a head injury .

in case of mannitol include

3.Phenytoin levels may

often performed to

intracranial pressure and

decrease when the

from a subdural

demonstrate the

cerebral blood flow using laser

suspension is given

hematoma can be life-

subdural hematoma is

Doppler flowmetry.

with enteral feedings.

improving.

*Phenytoin admimistration

This could lead to a loss

should need to monitor the

of seizure control hence

forehead around 5 x

Current medication:

threatening. Some

1.5 cm.

Inj . Piracetam 12g BD

subdural hematomas

with 500 ml NS

stop and resolve

2. The required therapy

parameters of cardiovascular

interrupt the feeding for

PMH: Non-

Inj. Citicoline 500mg

spontaneously; others

for sub dural

system because of the risk of

2 hours before and after

remarkable prior to

BD

require surgical

hemorrhage is to

severe hypertension and

the phenytoin dose.

admission.

Inj . Mannitol 20% BD

drainage.

prevent the bleeding in

cardiac arrhythmias.

Inj. Phenytoin 100mg

the sub dural space of

*cardiac monitoring and blood

TDS

brain.

pressure monitoring should be

Inj. Pantaprazole 40mg

done while using

OD

pantoprazole.

Inj. Ondansetron 4mg

OD

3. .MRI should done if needed.

Department of Pharmacy Practice, Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor-517127 (AP), INDIA

Case No.:
Date:
Inj. Meropenam 1g BD

Repeated head imaging tests

Inj. Imipenem and

are often performed to

Cilastatin 1g BD

demonstrate the subdural

hematoma is improving.
4. anti coagulants should be
avoided because it worsen the
hemorrhage.

Department of Pharmacy Practice, Sri Venkateswara College of Pharmacy, RVS Nagar, Chittoor-517127 (AP), INDIA