A 55 year old male with altered sensorium under evaluation

 Case of a 55 year old male with altered sensorium.

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A 55 year old male came to op on 4th October with chief complaints of altered sensorium since since one day and history of headache and he took two hypertensive tablets .

History of presenting illness:

The patient was apparently a symptomatic one day back and then he had headache which was sudden in onset and radiating to the neck and he took two tablets of hypertensive medications. Later he developed altered sensorium since evening.patients attenders observed irrelevant behaviour in him since night.

There is no history of chest pain ,palpitations, no involuntary movements, uprolling of eyes,frothing from mouth,deviation of mouth to left side present .

Past history:

CAD Six years back he had chest pain radiating to left arm and was taken to hospital. ECG shown MI pattern ,CABG was done and on medication since then.

Medical history: known case of hypertension since 6 years.

 Diabetes : no

Tuberculosis:no

Epilepsy:no

No significant surgically history.

No transfusion of blood.

Personal history: 

Diet mixed

Appetite normal bowel and bladder regular

No known allergies 

Alcohol occasional

No significant family history.

Non smoker 

General examination :patient is conscious but not oriented to place and cooperative.

Pallor no

Icterus no

Cyanosis no

Clubbing no 

Lymphadenopathy no 

Edema no 

Vitals:

Pulse rate 78bpm, regular , normal volume.

Blood pressure 170/90 mm/Hg

Respiratory rate18 cpm

Temperature afebrile

Systemic examination:

CVS:S1 and S2 heart sounds heard.

No murmurs heard

RESPIRATORY SYSTEM

Position of the trachea central

BAE present , vesicular breath sounds heard

Patient is not dyspenic 

Abdomen examination 

On inspection shape of the abdomen is scaphoid 

scar of the previous CABG seen 

Palpation: liver and spleen not palpable sand ko palpable masses.

Hernial orifices are free.

No free fluid no bruits 

bowel sounds heard.

CNS

Patient is conscious, non coherent , not oriented to place.

Speech : slurred

Power  U/L         L/L

   Right   3/5         3/5

    Left      5/5        5/5

Tone        U/L                    L/L

Right       Decreased        Decreased

Left          Normal             Normal 

Reflexes   Biceps triceps supinator knee ankle 

Right        2+        3+          +              +        +

Left          3+        3+         3+            2+        2+

Pupil : NSRL

Conjunctival reflex +

Corneal reflex

No meningeal signs.

On 8th October 

Patient sensorium has improved and responding to commands.

Slurred speech still present

Investigations

GRBS :99mg/dl

Provisional diagnosis:right sided Hemiparesis and  altered sensorium secondary to infarcts in the brain???

Treatment:

1) head end elevation 

2)Inj.MANNITOL 100mg IV BD

3)tab.ECOSPIRIN

4)Inj.OPTINEURON I ampoules one NS IV OD

5)tab AMLONG RO /OF at 8:00am

6)physio therapy for right upper limb and right lower limb.

Patient discharged on 12th oct to have surgery at another centre.