This is a 32 year-old male found by police at a bus stop confused and
bleeding from his chin. He doesn’t know what happened. Denies fighting
or previous seizure. Drinks alcohol daily and occasionally uses crack
cocaine. Last drink was today he thinks.
ROS negative for weakness, headache, sensory loss, vision change, gait
trouble. He does feel shaky.
2. Clavicle fracture
3. Alcohol abuse
Family History: Adopted.
Social History: Homeless. No regular medical care. Smokes
1/2 ppd. 8-12 cans beer per day. No IVDU.
BP 110/74 HR 108
General: Disheveled. Beard with dried and fresh blood
on the chin. Mildly dysarthric. Cervical collar in place.
Mental Status: Confused. Hallucinating. Oriented times
HEENT: Poor dentition. PERRLA. EOMI. Visual fields full.
Ear canals clear. No mastoid hematoma.
Motor (Power/Tone/Bulk): 5/5
Sensory: Can’t test secondary to mental status.
Reflexes: 1/4 at the right biceps, 2/4 at the left; 2/4
at the right triceps, 3/4 at the left; 1/4 wrists; 2/4 at the right knee,
3/4 at the left; 1/4 ankles. Right toe downgoing and left toe mute.
Coordination: FNF symmetric.
Gait: Mild ataxia. Veered to the left.
Abnormal Movements: Action tremor on both sides.
Other Organs: Diffuse abdominal pain.