75F recent ALTERED SENSORIUM right hemiparesis

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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.

75/F presented to casuality in drowsy state at 7:45pm.

History of presenting illness  

Patient was apparently asymptomatic till afternoon after which patient had sudden loss of consciousness followed by fall after which patient became altered and was not coherent and confused. BP after the fall was around 170/110. No history of seizure activity.

No H/o frothing, up rolling of eye balls, involuntary micturition and defecation. No H/o ENT bleed, projectile vomitings. 

Past history 

N/k/c/o DM, HTN, asthma, epilepsy, TB, thyroid disorders.

On examination 

Patient is drowsy but arousal.

GCS:E3V4M6

BP:110/80mmhg.

PR:92/min

RR:18CPM

SPO2:98%ON ROOM AIR 

TEMP: 98°F

CVS:S1,S2 HEARD,NO MURMURS. 

RS:BAE+,NVBS.

PA:SOFT AND NONTENDER 

CNS:PUPILS :NORMAL SIZE AND NON REACTIVE. 

TONE: RT. LT

        UL HYPOTONIA NORMAL

    

  LL HYPOTONIA NORMAL

POWER:

        UL 0/5. 4/5   

        LL 0/5. 4/5

REFLEXES:

        B: 2+ 2+

        T: 2+ 2+

        S: 2+ 2+

        K: 3+ 2+

        A: 1+ 2+

        P: EXT. FLEXOR

PROVISIONAL DIAGNOSIS 

ALTERED SENSORIUM (RESOLVED) 2°TO ?ACUTE HEMORRHAGIC STROKE (SUBACUTE HEMATOMA IN LEFT PARIED OCCIPITAL REGEION).

On 02/05/2023

S:

4 FEVER SPIKES SINCE YESTERDAY MORNING

STOOLS PASSED 

O:

ON EXAMINATION:

Patient is conscious but not oriented. 

Gcs:E4V5M6

BP:140/90mmhg.

PR:98BPM

RR:18CPM

TEMP:96.7°F

CVS:S1,S2 HEARD ,NO MURMURS. 

RS:BAE+,NVBS.

CNS:PUPILS:B/L NORMAL SIZE REACTING TO LIGHT.

TONE: RT. LT

   UL: HYPOTONIA NORMAL

    

  LL:. HYPOTONIA NORMAL

POWER:

   UL. 0/5. 3/5   

    LL. 0/5. 3/5

REFLEXES:

        B: 2+ 2+

        T: 2+ 2+

        S: 2+ 2+

        K: 3+ 2+

        A: 1+ 1+

        P: EXT. FLEXOR

A:

ALTERED SENSORIUM (RESOLVED) 2°TO ?ACUTE HEMORRHAGIC STROKE (SUBACUTE HEMATOMA IN LEFT PARIED OCCIPITAL REGEION).

P:

RYLES FEED :100ML WATER EVERY 2ND HOURLY 

200ML MILK EVERY 4TH HOURLY. 

INJ. MANNITOL 100ML IV/ TID 

MONITORING VITALS HOURLY