Case presentation Int:雲智謙 99.xx.xx.

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Presentation transcript:

Case presentation Int:雲智謙 99.xx.xx

Name: Gender： Age： Chart No. : Date of admission:2010/xx/xx

Chief complaint

Present illness The …

Present illness The …

Present illness The …

Present illness The …

Present illness The …

Present illness The …

Present illness The …

Past history DM: HTN: HBV/HCV: denied CVA CAD Asthma: denied Other systemic disease: denied Hospitalization history: denied

PE Consiousness: clear GCS: E4 V5 M6 Vital sign:BP: / mmHg, PR: bpm, RR: cpm, BT: ℃ Sclera: , conjuctiva: Neck: Supple, Lymphadenopathy(-) Chest: Inspection: symmetrical expansion Auscultation: Bil. clear breathing sound, crackles(-) , regular heart sound, murmur(-) Abdomen: Extremities: pitting edema(-), ecchymosis(-),

NE – high cortical function JOMAC Judgement: fair Orientation: to 人 : fair to 時 : fair to 地 : fair Speech: dysarthria(-) Language: Fluency: ok, Repetition:ok, Comprehension:ok, Naming:ok

NE – cranial nerves I: smell: not test II: VA: not test VF: not test II+III: light reflex R't / L't ( +/ + ) ( 3.0 mm/ 3.0 mm) III+IV+VI: 0 0 0 0 0─┼x┼─0 0─┼x┼─0 V: sensation: light touch: fair thermal: fair pin-prick: fair motor: masseter、temporalis: fair V+VII: corneal reflex: fair VII: no facial palsy VIII:no hearing impairment

NE- cranial nerves IX+X: uvula deviation: central position gag reflex: fair XI: trapezius: fair SCM: fair XII: tongue deviation: no deviation

NE – muscle tones and powers Muscle tone: upper normal lower increased Muscle power Right Left Upper extremities Lower extremities

NE - DTR DTR right left biceps ++ ++ triceps ++ ++ brachilis ++ ++ knee +++ +++ achillis +++ +++ Barbinski sign: dorsal- flex dorsal-flex

NE – sensory function pin-prick: bilateral lower limbs numbness light touch: bilateral lower limbs numbness vibration: bilateral lower limbs numbness position sense: bilateral poor

NE – motor function

Lab data

Lab data

Available image MR

Different diagnosis r/o

Tentative Diagnosis