This is an online E Log book recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.
Hi, I Aswin.I 6th 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
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
H/o trauma (RTA) 10yrs back
Personal history
Appetite normal
Mixed diet
Regular bowel movements
Sleep adequate
No smoking
Occasional drinker
General examination
Patient was conscious coherent and we'll oriented to time place and person.
•No pallor
•No icterus
•No cyanosis
•No clubbing of fingers
•No pedal edema
•No lymphadenopathy
Vitals
•Blood pressure = 130/90 mmhg
•Pulse rate = 71 beats/min
•Temperature = Afebrile (normal)
•Respiratory rate = 16cycles/min.
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
Liver not palpable
Spleen not palpable
Bowel sounds (+)
Central nervous system
Conscious
Speech is normal
Sensory system :normal
Motor system:
Left. Right
Power 5/5. Power 1/5
Tone good. Tone decreased
Pupils: Bilateral normal and reactive to light
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