You are working in the Emergency Department and get asked to see a 76-year-old unwell man. The patient was found by his wife slumped across the breakfast table. An ambulance was called. His wife is very concerned because his speech is now slurred. You start to assess the patient using the ABCDE approach.

After assessing A to C and finding nothing of concern you proceed to assess the patient’s GCS. The patient is lying on the trolley with his eyes closed, making incomprehensible noises. When you press on his supraorbital ridge he opens his eyes and moves his hand to brush you away.

What is his GCS?

E2M5V2 (9/15)

His blood glucose level is normal at 4.7 mmol/L.

What are 4 causes of hypoglycaemia?

On examination you find that he has a left facial droop and a left sided hemiplegia. His pupils are equal and reactive.

Can you think of one pathological causes of uneven pupils and one non-pathological cause?

Pathological causes


What further information would you like to get from his wife?

The patient's wife tells you he has been suffering from high blood pressure but has not been taking his antihypertensive medication prescribed by the GP. He drinks 8 units of alcohol a day.

What further investigations would you like?

The patient is transferred to the radiology department for a CT head.

What potential abnormalities might be found?

The patient has left sided focal neurology, which suggests right-sided brain pathology. Blood is easily seen on a CT scan. The differential diagnosis would include a spontaneous intra-parenchymal haemorrhage or subdural haematoma. A subarachnoid haemorrhage usually presents with a headache and an extradural haemorrhage usually occurs as a result of trauma but both may also be possible. An ischaemic stroke would present in this way but often a CT head is usually normal at this early stage.

The radiologist has reported there is a large right-sided intra-parenchymal haemorrhage. On the patient’s return he is noted to start convulsing. It is a tonic-clonic generalised seizure.

How would you manage this situation?