Post by erinto on Jan 11, 2016 8:19:32 GMT -5
33 yo black male, with HTN and mild MRDD. Patient has a one month history of headaches, with blurred vision, and not feeling well. He denies fever, chills, vomiting, trauma, falls, ataxia, and any focal weakness. His vision seemed worse, so he told his mother, who brought him in. VS were 36.9-144-150/82-18. Exam was nonfocal. He was tachycardic, but clear lungs, no M/R/G, no fever, moving all extremities, no evidence of any injury. Visual acuity was 20/30, 20/20, and 20/20 bilaterally. He had a small lesion on his lower lip, which looked to be traumatic, but he said he might have bit it, or injured it brushing his teeth.
He is healthy, only takes medication for his HTN, no psychotropics. No history of seizures.
CT scan of head was ordered:
1. Subdural collection on the left which appears be a hematoma with
areas of hyperdensity suggesting acute hemorrhage. An underlying
extra-axial lesion cannot be excluded therefore follow-up MR imaging
may be helpful.
Neurosurgery was called with plans to take him to the OR.
Thoughts, particularly, are you worried about the tachycardia, or is this something you can expect with this CT finding? Would you be worried about anything else?
He is healthy, only takes medication for his HTN, no psychotropics. No history of seizures.
CT scan of head was ordered:
1. Subdural collection on the left which appears be a hematoma with
areas of hyperdensity suggesting acute hemorrhage. An underlying
extra-axial lesion cannot be excluded therefore follow-up MR imaging
may be helpful.
Neurosurgery was called with plans to take him to the OR.
Thoughts, particularly, are you worried about the tachycardia, or is this something you can expect with this CT finding? Would you be worried about anything else?
