A CASE OF ALTERED SENSORIUM UNDER EVALUATION PRIMARIY TO HEAD INJURY....ELOG BY SAIPRANEETH BATHINEEDI
A CASE FROM GENERAL MEDICINE DEPARTMENT;
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CHIEF COMPLAINT;
A 55 YR OLD MALE PATIENT FARMER BY OCCUPATION CAME TO THE OPD WITH CHIEF COMPLAINTS OF WEAKNESS OF RIGHT SIDED UPPERLIMB AND LOWER LIMB WITH SLURRING OF SPEECH;
HISTORY OF PRESENTING ILLNESS;
The patient was apparently assymptomatic 10 days back when he had a head injury(no external bleeding) and started behaving differently(like a child as described by the patients attender)since then he developed gradual weakness to his limbs with intermittent severe headaches;
He takes his antihypertensive medication only when he has severe bouts of headache;
Before he was admitted into our hospital, he took 3 BP (UNKNOWN) tablets for severe headache and later he called his family members for help as he was unable to get up from bed and he was seen dragging his legs even when given support(as described by the patients attender) and soon he was taken to a local hospital in miryalguda where he was admitted for a night and referred to our hospital next day as he had high chances of getting paralysis(doctors advice in that local hospital);
He was shifted to the ICU ward where he is currently undergoing treatment;
5 years back he underwent some cardiac surgery stating the cause as heart failure;where he refrained himself from taking alcohol(beer and toddy occasionally) since then;
6 months back when he started drinking alcohol again he had a facial edema for which he was taken to a local hospital and got treated; since then he used to have alcohol once in 2-3 months as described by his wife;
PAST HISTORY;
K\C\O HYPERTENSION SINCE 4 YEARS;
NO H\O DIABETES MELLITUS,TB OR ANY OTHER CHRONIC ILLNESSES;
CARDIAC SURGERY 5 YEARS BACK;
PERSONAL HISTORY;
DIET-MIXED DIET;NORMAL APPETITE
SLEEP-ADEQUATE;
BLADDER AND BOWEL MOVEMENTS-REGULAR;
ALCOHOLIC(1 BEER NOT ONN A REGULAR BASIS AND OCCASIONALLY TODDY);NO H\0 SMOKING
GENERAL EXAMINATION;
THE PATIENT IS CONSCIOUS AND ORIENTED TO PERSON AND PLACE BUT NOT TIME;
HE IS MODERATELY BUILT AND WELL NOURISHED;
SLIGHT ICTERUS;
NO H\O PALLOR,CYANOSIS,CLUBBING, PEDAL EDEMA AND LYMPHADENOPATHY;
VITALS;
ON 7\10\21- AFEBRILE; BP -160\90 mmHg; RR- 17 TIMES\MIN;PULSE RATE-94 BEATS\MIN;
ON 8\10\21 -AFEBRILE; BP -160\110 mm Hg; RR- 16 TIMES\MIN; PULSE RATE-71 BETAS \MIN;
SYSTEMIC EXAMINATION;
CNS:
Level of consciousness- drowsy with slight improvement in the response from the patient;
Speech- slurred and slowed;
Deviation of mouth to the left while talking;
Motor system:
Rt Lt
TONE;
UL DECREASED N
LL. DECREASED N
POWER;
UL. 4/5. 4/5
LL. 4/5. 4/5
CRANIAL NERVE EXAMINATION;
CN 1; NORMAL;
CN 2; NO EXAMIATION WAS DONE;
CN 3,4,6;NORMAL;
CN 5; SENSORY COMPONENT IS NORMAL;NOT ABLE TO CHEW FOOD;
CN 7; DEVIATION OF MOUTH TO LEFT, ABLE TO CLOSE HIS EYES AND LIPS NO DROOLING OF SALIVA;
CN 8;ABLE TO HEAR NORMALLY;;COULDNOT DO THE TUNING FORK TESTS
CN 9 AND 10; DIFFICULTY IN SPEECH AND SWALLOWING;
CN 11; NORMAL;
CN 12;ABLE TO ROLL THE TONGUE;
REFLEXES;
CORNEAL AND CONJUNCTIVAL REFLEXES WERE PRESENT;
PROVISIONAL DIAGNOSIS; RIGHT SIDES PARAPERSIS OF UPPERLIMB AND LOWER LIMB WITH ALTERED SENSORIUM SECONDARY TO ? CVA
CLINICAL IMAGES AND INVESTIGATIONS;
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