A 68 year old male with altered sensorium
Polagoni Divya
Roll no.01. (old batch)
3rd semester
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A 68 year old Male with altered sensorium
Following is the view of my case:
CHIEF COMPLAINTS:
Patient presented to the casualty in an altered state with GCS E4V1M4
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic until one and a half hour ago when he was going for a nature call and was made to sit on a chair and then he suddenly became altered with a history of fall.
There was history of deviation of mouth to right
No history of involuntary movements, urinary incontinence.
No history of nausea and vomiting.
No h/o head injury,Uprolling of eye balls
No h/o post ictal confusion
PAST HISTORY:
K/C/O Asthma since 14 years and on MDI
K/C/O HTN since 7 years and on amlong.
K/C/O of CVA in august 2020 with MCA
ischaemic infarct with unresolved AF and with inferior wall MI.
Not a k/c/o Type 2 diabetes, TB
FAMILY HISTORY:
No history of similar complaints in the family.
No history of DM, TB, Stroke, Asthma, or any other hereditary diseases in the family.
DRUG HISTORY:
T.Amlong 2.5mg PO OD for HTN.
T Amiodarone 150mg PO BD
PERSONAL HISTORY:
Appetite: Normal
Diet: Mixed
Bowel movements: Regular
Bladder movements: Normal
No known allergies
No addictions
GENERAL EXAMINATION:
The patient is examined in a well lit room with informed consent.
The patient is not conscious, coherent and cooperative and is not oriented to time, place and person.
He is moderately built and nourished.
Pallor: Absent
Icterus: Absent
Cyanosis: Absent
Clubbing: Absent
Lymphadenopathy: Absent
Edema: Absent
VITALS:
On 24/6/21 (At the time of admission):
Temperature- 98.4F
Heart Rate- 132 BPM
Blood Pressure- 180/120 mm of Hg
SPO2- 97% at room air
Respiratory rate- 18/min
GRBS- 151 mg%
SYSTEMIC EXAMINATION:
CVS SYSTEM: S1,S2 heard
No added thrills, no murmurs
RESPIRATORY SYSTEM:
Position of trachea: Central
Breath sounds: Vesicular breath sounds heard
Adventitious sounds: Not heard
PER ABDOMEN:
Soft, non tender, no organomegaly
CNS:
Level of consciousness: stuporous
Speech: no response
Cranial nerves could not be evaluated on presentation
7th nerve examination: Deviation of mouth to right side
On 25/6/21:
Cranial nerves intact
Motor system:
Power:
Right sided 4+/5
left UL - 0/5
LL - 3/5
Tone:
Right side normal tone both UL and LL
LEFT SIDE tone increased in both UL AND LL
Reflexes:
RT SIDED
biceps 3+ , triceps 1+ ,supinator 1+,knee 3+, ankle 2+
LT SIDED
biceps 3+, triceps 3+ , supinator 3+ , knee 3+, ankle 2+
No cerebellar signs
Investigations:
1) serum electrolytes
On 25/6/21:
Cranial nerves intact
Motor system:
Power:
Right sided 4+/5
left UL - 0/5
LL - 3/5
Tone:
Right side normal tone both UL and LL
LEFT SIDE tone increased in both UL AND LL
Reflexes:
RT SIDED
biceps 3+ , triceps 1+ ,supinator 1+,knee 3+, ankle 2+
LT SIDED
biceps 3+, triceps 3+ , supinator 3+ , knee 3+, ankle 2+
No cerebellar signs
INVESTIGATIONS:
1) Serum electrolytes
Altered sensorium under evaluation
(Intracranial bleed ruled out)
Summary:
The person has asthma since 14 years no history complaints in the family no thrills the diagnosis is altered sensorium under evaluation.
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