A 60 Yr old male with altered sensorium

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 This is online E log book to discuss out patients de-identified health data shared after taking his / her guardian`s informed consent. Here we discuss our individual patient`s problems through series of inputs from available global online community of experts with an aim to solve patients clinical problems with collective current best evidence based inputs. 

     This E log book also reflects my patient centered online learning portfolio and your valuable inputs on comments box is welcome.

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.

Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references

C/O :

Headache since 1 day

Neck pain since 1 day

Altered sensorium since morning 

HOPI: 

Patient was apparently asymptomatic 1 day back ,then he developed headache-b/l frontal and occipital region .

Neck pain since 1 days radiating to b/l upper limbs 

Altered sensorium since morning -irrelevant talking, not able to identify the attender .No H/o head injury /Fall .No H/O involuntary movements in B/L upper and lower limbs .No H/O involuntary micturition or defecation 

SEQUENCE OF EVENTS :

Headache and neck pain -09/08/23.   

On 10-08-23 ,he woke up at 6 am and was speaking well to the attender 

According to the attender(wife) ,patient went to bathroom and when he came back he was staring at the attender 

Upon asking what happened he was talking irrelevantly and he couldn't recognise the attender 

PAST HISTORY:

-Not a K/C/O DM,HTN,Asthma,TB,Epilepsy 

-No H/O trauma/Fall in the past 

-No H/O any surgeries 


PERSONAL HISTORY :

Diet -mixed

Appetite-Normal

Sleep-adequate

Bowel/Bladder - Regular

Addictions-consumes alcohol regularly since 3 years 

Allergies-None 


GENERAL EXAMINATION :

No signs of pallor, icterus, cyanosis, clubbing, Lymphadenopathy, pedal edema










VITALS ON ADMISSION : 

PR : 78 bpm

BP : 120/70 mmhg 

TEMPERATURE : 100.2 F

RR : 18 cpm

Spo2 : 98 % on 8 lit O2

GRBS : 110 mg/dl  


SYSTEMIC EXAMINATION : 


RESPIRATORY SYSTEM EXAMINATION : 

Bilateral air entry +

Normal vesicular breath sounds


CVS EXAMINATION : 

S1, S2 heard 

No murmurs 


ABDOMEN EXAMINATION : 

No tenderness 

No organomegaly

Bowel sounds - present 


CNS EXAMINATION : 

Cranial nerve examination - cannot be elicited 

Sensory examination -cannot be elicited 

Motor examination 

                                        Rt                                         lt 

POWER-UL                     5/5                                        5/5

              -LL                      5/5                                        5/5

TONE -UL                         Normal                              Normal 

            -LL                         Normal                              Normal 

REFLEXES-

          -Biceps.                      2+                                        2+ 

          -Triceps                     2+                                        2+  

          -Knee                          1+                                        1+

          - Ankle                         -                                           -

No signs of meningeal irritation


INVESTIGATIONS:
















PROVISIONAL DIAGNOSIS : 

Altered sensorium secondary to Acute CVA 

TREATMENT :

1.Inj Neomol 1 gm IV Stat 

2.Monitor vitals 


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