43year old male came with the

 

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