Current Status
Not Enrolled
Price
Free
Get Started

Author: Mars Christian Aragon Sta Ines / Editor: Sarah Edwards / Codes: ELP10, ELP2, NeuC9, SLO1 / Published: 18/11/2024

A 67-year-old male is referred by the GP with a 3-month history of progressive unsteadiness. He also complains of decreased mobility described as taking slow, small steps when walking and sometimes dragging feet along without lifting them fully from the ground, which is very unusual for him. Over the last 26 hrs, his husband has noticed right facial drooping (BEFAST+) and developed rigidity on both of his lower limbs.

The patient has no history of falls or recent trauma, no signs and symptoms of non-accidental injury, infection or malignancy. He hasn’t used any recreational drugs.

Past medical History

  • Hypertension
  • Diabetes

Family history

The patient has a family history of memory loss from his mother side.

Social history

He is an independent retired teacher, and volunteers in a pet shop. He is an ex-smoker (10 years) and social alcohol drinker. He has no walking frame.

Allergies

  • Penicillin

Medications

  • Amlodipine 10 mg/tab OD (recent change) from Amlodipine 5 mg/tab OD
  • Metformin 500 mg/tab BD

Examination

  • A- Patent airway, slightly dry oral mucosa
  • B- Respiratory Rate 20 Oxygen saturations 96%
    • Symmetric chest expansion, decreased breath sounds on right base
    • No central or peripheral cyanosis
    • Chest x-ray normal
  • C- Blood pressure 160/100 Heart Rate 90
    • Heart sound normal, ECG normal
    • Abdomen, soft, non-tender
    • Pulses full and equal, central and peripheral CRT <2 seconds
  • D- GCS 14-15 (confused fluctuating)
    • Neuro exam – normal
    • 2-3 mm pupils were equal and reactive
    • Blood sugar 12
  • E- Temperature 37.4 no rashes, no signs of meningism.