43year old male came with the     






chief complaints of 




Fall due to loss of consciousness on 4/4/23

Hopi-

Patient was apparently asymptomatic till yesterday morning then he had sudden loss of consciousness followed by fall on a cement brick and his clavicle fractured, he had similar complaint in the afternoon. No history of stiffness of both upper and lower limbs up rolling of eye balls , tounge bite .

No history of fever, vomiting, neck stiffness, neck pain , and headache . 

No history of visual disturbances. 

No history of head trauma . 

No history of sob , chest pain , palpitations, orthopnea . 

Past history 

K/c/o DM since 4years and was on medication 

K/c/o HTN since 3 years

Not a k/c/o asthma , tb , epilepsy and thyroid disorders 


Personal h/o 

Appetite- normal

Diet - mixed

Bowel and bladder - regular

Any known Allergies- absent

Addictions- alcohol- regular 180 ml /day , last intake yesterday morning. 


Family h/o - not significant


On general examination - 

patient is conscious,coherent and cooperative 

Well oriented to time , place and person. 

There is no pallor, icterus, cyanosis, clubbing, lymphadenopathy and bilateral pedal edema . 







Vitals- 

Temp - 99.2F

PR- 96 bpm

Bp- 110/70 mmhg

RR -26 cpm

Spo2-97%

Systemic examination -

Cvs- S1 S2 present , no murmurs . 

RS - BAE present, NVBS

P/A- soft, non tender and no organomegaly 

CNS :  

Higher mental functions 

Conscious , oriented to person , place and time .

Speech : normal 

Memory: intact 

No Visual hallucinations

No delusions 

No emotional liability 

CRANIAL NERVE EXAMINATION:


1st   : Normal


2nd  :  visual acuity is normal


                  

3rd,4th,6th  :  normal 

                        

5th             :  sensory intact


                      motor intact


7th             :  normal


8th             :  No abnormality noted.


9th,10th     : palatal movements present and equal. 


11 th : intact 

12 th : normal 


Motar examination 


              RT                               LT 

             UL      LL               UL    LL

Bulk : Normal Normal Normal Normally 

Tone : Normal Normal Normal Normally

Power : 5/5   5/5                5/5    5/5


Reflexes :   biceps: present   present present 

 

                    Triceps : present   present present    


                   Knee: present   present present present    


                   Ankle : present   present present present    



           


SENSORY EXAMINATION:  


SPINOTHALAMIC SENSATION:


Crude touch : Normal


pain : Normal 


temperature : Normal 


DORSAL COLUMN SENSATION:


Fine touch : normal 


Vibration : normal 


Proprioception : normal 



Reflexes-

                     Right.        Left 

Biceps.         2+.               2+

Triceps.        2+.               2+

Supinator.    1+.               1+

Knee.           .  2+.              2+

Ankle.            1+.               1+ 


CORTICAL SENSATION:


Two point discrimination : normal 


Tactile localisation :  normal 


CEREBELLAR EXAMINATION:

 Slight tremors are present 

No Gait ataxia 

Nystagmus -absent 


Provisional diagnosis -

Seizure under evaluation 

Investigations - 

Chest x ray pa view 


Shoulder AP/Lateral view 




 





ECG 
Ultrasound 
         


                                                                                       Soap notes 

5/4/23
Unit-2
Date of admission-04/05/23
S

1 fever spikes present at 4am 
Pain over right shoulder 
Passed stools 
O 

Pt is c/c/c 
Afebrile on touch
Bp -120/90 mm hg
PR-76/min
Temp-98.2F
RR- 20 cpm
SPO2- 99 on room air 
GRBS-127mg/dl
Input-  700 ml
Output- 150ml
Systemic examination-
CVS-s1, s2 heard , no murmurs
RS-BAE , NVBS present 
P/A- soft , nontender
CNS- NAD


Hb 9.3
TC 4700
 N 70
L 22
Pcv 28.4
RBC 2.89
Platelets 50,000
Tb 2.10
Db 0.81
Alp 261
Blood urea 17
Creat 1.5
Uric acid 1.25
Na 138
K 3.0
Cl 98

A

Diagnosis -
Syncope under evaluation with thrombocytopenia 


P
IV fluids NS and RL @100ml/hr 
Inj thiamine 100mg in 100ml NS IV/BD 
WATCH for bleeding manifestation 
Temperature charting 4 th hrly 



  


        



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