65M Weakness of Right upper and lower limbs, neck pain 1 day Telangana PaJR

 11-10-2023

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.

65/M, Weakness of Rt Upper and lower limbs, Neck pain

October 11, 2023

C/o weakness in Right upper and lower limb

C/o neck pain

History of present illness:

Patient was brought to casuality with A/H/O fall (slip and fall) over the floor on face and has c/o pain in the back of neck and unable to move his Right upper and lower limbs since the event on 10/10/23 at around 5.30pm near Miryalaguda.

Patient has no other complaints except pain in back of neck and unable to move right upper limbs and lower limbs. 

No H/o nausea and vomiting

No H/o ent bleed

Cct - negative

Pct-negative

Cervical tenderness (+)

History of past illness:

H/o Trauma (RTA) 10yrs back

Not a known case of Hypertension, Diabetes, Cad, thyroid disorders, epilepsy etc

Personal history:

Appetite: normal

Retired Rtc mechanic (15yrs back Retired) 

Bowel and bladder habits: Regular

Diet: mixed

Addictions: occasionally Alcoholic nonsmoker 

Sleep: adequate

General examination:

Pt is c/c/c

No signs of clubbing, cyanosis, pallor ,icterus,lymphendenopathy 

Vitals :

10/10/23

Bp :130/90

PR:70bpm 

Temp:afebrile

RR:16counts per minute 

Systemic admission:

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

Laboratory investigations done on 11/10/23