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Emergency Mosicine Block 2019: Student Gu FOURTH PROBLEM A "Stormy" Shift eyes an sluggis You

are an attending emergency department physician when three patients are brought to the
Emergency Department (ED) at the same time with hi He wit The first patient, a 22-year-old man is
brought to the Emergency Department by his Discus family after seizing. His family describes the
patient's body was stiff, his teeth were clenching and eyes were widely open when scizing. The
seizure happened for about three times in an hour, each episode lasted for 2-3 minutes. Between
seizures appeared lethargic, drowsy and difficult to awaken. History of previo denied. He had been
coughing for some times, and curr and headache for a week. He took paracetamol to treat his fever
and headache, but his symptoms only slightly lessened. About a month ago, the patient t motorcycle
but he did not receive s seizure ently also experiences fever ell from a any treatment. He only had
several vaccinations His 25-year-old cousin is diagnosed with epilepsy two years ago but his
symptom is currently under-control. On initial examination, the patient appears soporous, GCS
E3M4V2. Blood pressure is 140/90 mmllg, heart rate is 100 beats per since birth. minute, respiratory
rate is 28 breaths per minutes and temperature is 38.8 °C. The second patient, a 50-year-old man is
brought to the Emergency Department by paramedics after he was found unconscious with his face
down on the bathroom floor by his wife. Traces of vomit were found around his mouth and clothes.
His wife said that while the patient was being transported to the emergency department, he had
convulsion for three times. His wife said his face began to twitch from his right side, spread to his
right extremities and finally developed into a generalized convulsion About a weck ago, patient
started to experience headache, but his pain was getting better after taking paracetamol. However,
according to his wife, he woke up this morning with stiff neck and severe headache to the point that
he almost could not get up from the bed. He cried the back of his head felt like being tightly
constricted and the pain is getting worse when he saw bright light. He has a history of uncontrolled
hypertension for three years. He smokes 1-2 packs of cigarettes a day and sometimes drinks alcohol
with his office mates. On initial examination in the ED, GCS E2M4V2 His blood pressure is 180/100
mmlig, heart rate is 60 beats per minutes rates is 20 breaths per minutes and temperature 37.8 °C.
While performing "doll's eyes manuever, there are signs of bilateral facial nerve paralysis. All
meningeal signs are positive. minutes, respiratory The third patient, a 30-year-old man, is brought to
the ED by paramedics after he was assaulted with a blow to the head while walking home. He lost
consciousness temporarily, but woke up and went home to recover. Several hours later, his wife
called the ambulance because she notices that the patient is acting confused and has become less
responsive progressively. On physical examination the patient was noted to have a tense subgaleal
hematoma that is palpable on the right side of his head. His OUNTAT

The second patient, a 50-year-old man is brought to the Emergency Department by paramedics after
he was found unconscious with his face down on the bathroom floor by his wife.Traces of vomit
were found around his mouth and clothes.His wife said that while the patient was being transported
to the emergency department, he had convulsion for three times.His wife said his face began to
twitch from his right side, spread to his right extremities and finally developed into a generalized
convulsion.About a week ago, patient started to experience headache, but his pain was getting
better after taking paracetamol.However, according to his wife, he woke up this morning with stiff
neck and severe headache to the point that he almost up from the bed.He cried the back of his head
felt like being tightly constricted and the pain is getting worse when he saw bright light.He has a
history of uncontrolled hypertension for three years.He smokes 1-2 packs of cigarettes a day and
sometimes alcohol with his office mates.On initial examination in the ED, GCS E2M4V2.blood
pressure is 180/100 mmHg, heart rate is 60 beats per minutes, respiratory 20 breaths per minutes
and temperature 37.8 °C.While performing "doll's there are signs of bilateral facial nerve paralysis.
All meningeal signs could not get

The third patient, a 30-year-old man, is brought to the ED by paramedics after he was assaulted with
a blow to the head while walking home. He lost consciousness temporarily, but woke up and went
home to recover. Several hours later, his wife called the ambulance because she notices that the
patient is acting confused and has become less responsive progressively. On physical examination
the patient was noted to have a tense subgaleal hematoma that is palpable on the right side of his
head. His

eyes are closed and he does not open them to command. His left pupil is 6 mm and sluggishly
reactive. His right pupil is 4 mm and briskly reactive. He localizes to pain vith his left upper extremity
and withdraws from pain with his right upper extremity He withdraws from pain briskly in his lower
extremities Discuss the cases, assess the patients's condition, plan the necessary examinations to
diagnose and plan proper treatment while considering all possibilities!