60yr old male with headache and altered sensorium

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 
Ecg

PROVISIONAL DIAGNOSIS : 
Altered sensorium secondary to Acute CVA 

TREATMENT :
1.Inj Neomol 1 gm IV Stat 

2.Monitor vitals 










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