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CERVICAL MYELOPATHY

01/DEC/2021

IMMANI AASRITHA, GM
3rd sem, roll num:49
Cervical myelopathy acute on chronic SDH

This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.
I have 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.
ON GOING CASE

CASE SCENARIO:
A 60 year old male came to opd with c/o vomiting and giddiness since 15 days
HOPI:
Patient was apparently asymptomatic 2 months back, had history of head injury following which patient went to hospitalhospital and diagnosed with subdural hematoma and treated conservatively.
Since 15 days patient had vomitings immediately after food intake, which is non bilious and non projectile, food particles as contents not a/w pain abdomen, no loose stools, no fever, no cough.
HISTORY OF PAST ILLNESS:
N/K/C/O HTN, DM
TREATMENT HISTORY
No significant treatment history
PERSONAL HISTORY
???
FAMILY HISTORY
No related family history
GENERAL EXAMINATION
Temperature: afebrile
Pulse rate: 68/min
Respiratory rate: 16/min
BP: 150/90 mm/Hg
SpO2: 98%
GRBS: 147mg%
SYSTEMIC EXAMINATION
CVS
Thrills:no
Cardiac sounds: s1, s2 heard 
Cardiac murmurs: no
Respiratory system
Dysponea: no
Wheezing: no
Position of trachea: central
Breath sounds: vesicular
ABDOMEN
No tenderness
No palpable mass
Henial orifice: normal
No free fluid
No bruits
Liver n spleen: not palpable
Bowel sounds: yes
CNS
Conscious and alert
Speech: normal
No signs of meningeal irritation
motor system: NAD
                   Right    Left 
Tone  UL.  N.          N
            LL.  N          N
Power UL  4+/5.  4+/5
             LL  4+/5.  4+/5
Reflexes-
            B-.   3+       3+
            T-     3+       3+
            S-.    3+.      3+
            K-     3+       3+
            A-     3+.      3+
CEREBELLAR SIGNS:
knee heel in- coordination - no
Finger nose in- coordination - no
PROVISIONAL DIAGNOSIS:
cervical myelopathy acute on chronic SDH
INVESTIGATION:
TREATMENT:



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