Author: Mars Christian Aragon Sta Ines / Editor: Sarah Edwards / Codes: / 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 hasnt 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.
