patient presents with history of fall

 Hi, I A satyanarayana 5 th sem medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning protofolia

  A 65 years old Male brought to hospital (Casualty) with

 

Cheif complaints

* Right upper limb and lower limb weakness

*Pain in neck

History of presenting illness

Patient was apparently asymptomatic till yesterday.Then he fall down over the floor on face(event occur around 5.30pm near miryaluguda and complaints of pain in neck (from 6.00pm on 10/10/23) sudden in onset and its not radiating and tenderness present on back of neck.

Unable to move his right upper limb and lower limb.

No micturition since fall

•No history of nausea, vomiting,nose bleed,ear bleed

•No history of fever

Past history

Not a known case of 

    Hypertension

    Diabetes

    Asthma

    Tuberculosis

    Epilepsy

Personal history

    Appetite normal

    Mixed diet

    Regular bowel movements

    Sleep disturbances due to pain

    No smoking

    Occasional drinker

GENERAL EXAMINATION

The patient was conscious coherent well oriented to time, place , person.. examination was done in a well ventilated room

  No pallor

No icterus 

No clubbing

No cyanosis

No pedal edema

VITALS:

* Temperature :Afebrile

* Blood pressure :130/90

* Pulse:70beats per minute

* Respiration rate:16cpm

SYSTEMIC EXAMINATION:

Cardiovascular system 

S1s2(+), no thrills, no murmurs 

Respiratory system

No dyspnoea

No wheeze

Position of trachea central 

Breath sounds :vesicular 

No crepitations

Abdomen

Shape of abdomen: scaphoid 

No tenderness 

No palpable masses

No bruits

Liver not palpable 

Spleen not palpable

Bowel sounds (+) 

Central nervous system 

Conscious 

Speech is normal

Sensory system :normal

Motor system: 

             Left.                      Right

Upper.    Power 5/5.         Power 1/5

               Tone good.        Tone decreased 

Gcs: E4V5M6 15/15

Pupils: Bilateral normal and reactive to light

Radiological investigations done on 11/10/23