62year male with left intertrochanteric fracture and altered sensorium under evaluation

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I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. 

Chief complaints.

Patient came with complaints of fall 3days back and sustained injury to left hip.

Complaints of shortness of breath since 1day.

Complaints of altered sensorium since 6hours.

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 1year back and then developed left sided weakness.He was diagnosed with left sided hemiplegia.patient sustained a fall 3days back and had injuries to left hip,which was diagnosed as left intratrochanteric fracture outside hospital,where he was treated symptomatically outside hospital.patient developed shortness of breath during the course of hospital stay for which patient was referred to our hospital with altered sensorium since 6hours. 

No history of fever,vomitings.

History of feeds given in supine position.

HISTORY OF PAST ILLNESS

Known case of CVA,left hemiplegia.

Known case of hypertension on metxl medication.

No history of epilepsy,asthma, DM.

FAMILY HISTORY-no significant family history

On EXAMINATION.

Temp-Afebrile

Pr-93

Cvs-s1s2 heard

Rs-bae +b/l crepts+

P/a -soft 

Bp-100/70mmhg

Spo2-90% at room air

Grbs-156

TREATMENT 

patient was referred to orthopaedic and was diagnosed with left intertrochanteric fracture.

1.inj piptaz 4.5gm iv bd

2.inj pan40mg iv oD

3.nebulisation with duolin and budecort 6th hourly

4.tab ultracet 1/2tab qid

5.ivf dns,rl @100ml per hour.

6.tab shelcal ct po od

7.skin traction with 4kgs weight.

INVESTIGATIONS

ECG

chest xray