Abd soft, no bruising, appears non-tender

Pelvis stable

Extremities, no gross deformity or bleeding

Neurologic exam:

Pupils: Right dilated and very sluggish to react, left normal light response

Neck in c-collar

Motor: Decorticate response to pain on left, withdraw to pain on right.

Sensory: Appears to feel pain in all 4 extremities

Reflex: Normal patella, Babinski equivocal

Unable to test cranial nerves Mental status: Comatose

Unable to test cerebellar function.

According to the sign out doc, this just developed in the past 45 minutes. You quickly find his chart to locate the CT results, and there are none. According to the tech, he went to CT, but was too combative complaining of severe headache and demanding pain medications, so they brought him back without getting the CT. The sign out doc was never told this.

1. What is his GCS? Can someone be paralyzed on one side and have a normal GCS?

2. What is the likely diagnosis based on the history?

3. What do you need to do now?

4. What are 4 ways to decrease intracranial pressure?

5. If you had to do a burr hole (unlikely you would be doing it, but still possible) which side should you start with? Remember, he is decorticate on the left, and withdraws to pain on the right, and has a sluggish pupil on the right.

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