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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 



  


        



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