Skip to main content

43year old male came with the chief complaints of Fall due to loss of consciousness

43year old male came with the chief complaints of

Fall due to loss of consciousness on 4/4/23


Hopi-

Patient was apparently asymptomatic till yesterday morning then he had sudden loss of consciousness followed by fall on a cement brick and his clavicle fractured, he had similar complaint in the afternoon. No history of stiffness of both upper and lower limbs up rolling of eye balls , tounge bite .

No history of fever, vomiting, neck stiffness, neck pain , and headache . 

No history of visual disturbances. 

No history of head trauma . 

No history of sob , chest pain , palpitations, orthopnea . 

Past history 

K/c/o DM since 4years and was on medication 

K/c/o HTN since 3 years

Not a k/c/o asthma , tb , epilepsy and thyroid disorders 


Personal h/o 

Appetite- normal

Diet - mixed

Bowel and bladder - regular

Any known Allergies- absent

Addictions- alcohol- regular 180 ml /day , last intake yesterday morning. 


Family h/o - not significant


On general examination - 

patient is conscious,coherent and cooperative 

Well oriented to time , place and person. 

There is no pallor, icterus, cyanosis, clubbing, lymphadenopathy and bilateral pedal edema . 







Vitals- 

Temp - 99.2F

PR- 96 bpm

Bp- 110/70 mmhg

RR -26 cpm

Spo2-97%

Systemic examination -

Cvs- S1 S2 present , no murmurs . 

RS - BAE present, NVBS

P/A- soft, non tender and no organomegaly 

CNS :  

Higher mental functions 

Conscious , oriented to person , place and time .

Speech : normal 

Memory: intact 

No Visual hallucinations

No delusions 

No emotional liability 

CRANIAL NERVE EXAMINATION:


1st   : Normal


2nd  :  visual acuity is normal


                  

3rd,4th,6th  :  normal 

                        

5th             :  sensory intact


                      motor intact


7th             :  normal


8th             :  No abnormality noted.


9th,10th     : palatal movements present and equal. 


11 th : intact 

12 th : normal 


Motar examination 


              RT                               LT 

             UL      LL               UL    LL

Bulk : Normal Normal Normal Normally 

Tone : Normal Normal Normal Normally

Power : 5/5   5/5                5/5    5/5


Reflexes :   biceps: present   present present 

 

                    Triceps : present   present present    


                   Knee: present   present present present    


                   Ankle : present   present present present    



           


SENSORY EXAMINATION:  


SPINOTHALAMIC SENSATION:


Crude touch : Normal


pain : Normal 


temperature : Normal 


DORSAL COLUMN SENSATION:


Fine touch : normal 


Vibration : normal 


Proprioception : normal 



Reflexes-

                     Right.        Left 

Biceps.         2+.               2+

Triceps.        2+.               2+

Supinator.    1+.               1+

Knee.           .  2+.              2+

Ankle.            1+.               1+ 


CORTICAL SENSATION:


Two point discrimination : normal 


Tactile localisation :  normal 


CEREBELLAR EXAMINATION:

 Slight tremors are present 

No Gait ataxia 

Nystagmus -absent 


Provisional diagnosis -

Seizure under evaluation 

Investigations - 

Chest x ray pa view 


Shoulder AP/Lateral view 




 





ECG 
Ultrasound 
         


                                                                                       Soap notes 

5/4/23
Unit-2
Date of admission-04/05/23
S

1 fever spikes present at 4am 
Pain over right shoulder 
Passed stools 
O 

Pt is c/c/c 
Afebrile on touch
Bp -120/90 mm hg
PR-76/min
Temp-98.2F
RR- 20 cpm
SPO2- 99 on room air 
GRBS-127mg/dl
Input-  700 ml
Output- 150ml
Systemic examination-
CVS-s1, s2 heard , no murmurs
RS-BAE , NVBS present 
P/A- soft , nontender
CNS- NAD


Hb 9.3
TC 4700
 N 70
L 22
Pcv 28.4
RBC 2.89
Platelets 50,000
Tb 2.10
Db 0.81
Alp 261
Blood urea 17
Creat 1.5
Uric acid 1.25
Na 138
K 3.0
Cl 98

A

Diagnosis -
Syncope under evaluation with thrombocytopenia 


P
IV fluids NS and RL @100ml/hr 
Inj thiamine 100mg in 100ml NS IV/BD 
WATCH for bleeding manifestation 
Temperature charting 4 th hrly 



  


        



Comments

Post a Comment

Popular posts from this blog

70yr old male with altered sensorium secondary to ?Meningitis

Image
  Sri Nithya Roll.no-86 ICU-BED. NO -03 A 70 Years Old Man Who was a Farmer By Occupation Presented to Casualty With  Altered Sensorium Since 3 Days  Fever Since 20 Days  HOPI :  Patient Was Apparently Asymptomatic Till 2014 ; 2014 - Patient Had Fever Associated with Cough for which he went to Hospital & Was Diagnosed to Have ? Pneumonia with DENOVO DM2 & Was Prescribed with OHAs ( Tab.METFORMIN & Tab.GLIMIPRIDE ) 6 Months Back - Patient Had Fever Associated with Cough for Which he Went to Hospital & Said to Have High Sugars along with Lung Infection ; Got Treated & Discharged in a Hemodynamically Stable Manner.Started using insulin for Diabetes Since Then  20 Days Back : Patient Had Fever with Cough ; For Which He went to Hospital & Suspected to Have TB But Reports Turned out to be Negative & Patient Discharged as LAMA & When He Returned Home 3 Days Back He Gradually Developed Altered Sensorium & Couldn't Recognise His Attendants Past History :
Read more
Image
  CASE-1 1) Pulmonology (10 Marks)    A) Link to patient details:     https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html   Questions:   1) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem?   2) What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient?   3) What could be the causes for her current acute exacerbation?     4. Could the ATT have affected her symptoms? If so how?     5.What could be the causes for her electrolyte imbalance?   1)EVOLUTION OF EVENTS OF SYMPTOMATOLOGY    1)shortness of breath which is on and off since 20 years.     2)pedal  edema since 15 days up to the level of the ankle, pitting type. 3)facial puffiness since 1
Read more

65 year old female with complaints of involuntary movements of left upper limb since 1 day, cough since 4 days

Image
 M. Sri Nithya Roll. No -86 Unit-2 Chief compliants A 65 yr old female patient came to casualty with complaints of involuntary movements of Lt upper limb since 1 day  Cough since 4 days  HOPI  Pt was apparently asymptomatic 1 week ago then she developed generalised weakness , fell down from bed and complaints of pain in the hip  Involuntary movements of lt upper limb since 1 day to and fro  No history of speech abnormalities , weakness in the upper limb and lower limb . No H/o memory loss and abnormal posturing . Complaints of cough since 4 days ,it is productive scanty sputum - white to yellow ,non blood stained and non foul smelling  H/o inadequate controls of sugars from 4 months  N/H/o vomiting ,sob,loose stools ,pain abdomen K/c/o type 2 DM since 30 yrs on infusion since 10 yrs  ( Insulin - lispro 20-x-20 ) K/c/o HTN from 20 yrs on T prolomet - xl 50 mg  T. Atenolol 25 mg po/ od at 10 am K/c/o hypothyroidism from 15 yrs on thyronorm 75 mcg Previous treatment history Hospitalised 1
Read more