A 65 year old came to casualty on 10/10/2023

Hi I am, Anirudh Manne (roll no:11), 6th sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio.

 A 65yr old male came to casualty on 10/10/23 with history of fall

Chief complaints

Patient had suffered from fall on 10/10/23 and complains of pain in neck since fall

History of presenting illness

patient was apparently asymptomatic till yesterday 

Patient was brought to casualty with

History of fall (slips fall) over the floor on his left side of the face and has  pain in back of the neck unable to  move his right upper and lower limb(weakness)

since the event on 10/0/23 at his home at 5:30pm near miryalaguda.

pain in back of neck which is loacalised and non radiating severe in intensity

Tenderness present on site of pain

Past history 

Not a known case of 

• diabetes mellitus
• Hypertension 
• Epilepsy
• Asthma
• Tuberculosis
• History of cataract operation 

Personal history

• Appetite -normal
• Mixed diet
• Sleep disturbed due to pain
• No micturition since fall
• Bowel movements regular
• Occasional drinker
• No smoking 

Family history 

No significant family history 

General examination 

Patient was conscious coherent well oriented to time space and person 

Patient was examined in a well ventilated room after taking his consent

• No pallor
• No cyanosis 
• No icterus 
• No clubbing of fingers
• 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 examination:

• Shape of abdomen: scaphoid 
• No tenderness 
• No palpable masses
• Liver not palpable 
• Spleen not palpable
• Bowel sounds (+) 

Central nervous system :

• Conscious and coherent
• 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

Radiological investigations done on 11/10/23