Loss of Consciousness in a 50-yr-old Man

Physical Examination

  • General apperance: Awake; saliva and blood at corner of his mouth. He appears well-developed, and appearance is consistent with stated age.

  • Vital signs:
  • Temperature: 36.5° C (97.7° F)
  • Pulse: 80 beats/min and regular
  • BP: 165/90 mm Hg
  • Respirations: 20/min

  • Skin: Pink, warm, and dry, with a few punctate red spots on right lower leg

  • HEENT: No evidence of scalp trauma. Tympanic membranes are clear; there is a puncture wound on the bottom of his tongue. HEENT exam is otherwise unremarkable.

  • Pulmonary: No respiratory distress. Equal breath sounds bilaterally with good air entry/exit; no wheezing.

  • Cardiovascular: Regular rate and rhythm. Normal S1 and S2. No murmurs.

  • Gastrointestinal: Unremarkable

  • Genitourinary: Unremarkable except for urine on trousers.

  • Musculoskeletal: Full range of motion; no deformities, tenderness, or bruises.

  • Neurologic: Pupils are equal and normally reactive to light with no nystagmus. Face appears symmetric; gag reflex is present and symmetric. The patient can move all limbs equally to command but patient does not comprehend commands for more detailed motor function testing. Deep tendon reflexes are symmetric and 2+ throughout; plantar reflexes are downgoing bilaterally. No meningismus.

  • Mental status: Awake; eyes open. Oriented only to name; gives confused, incoherent responses to other questions; follows simple commands using all limbs.