43 Male came with LOC

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

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 

Soap notes 

Unit-2

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 ble

eding manifestation 

Temperature charting 4 th hrly