1. Case presentation
Int:雲智謙
99.xx.xx

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

3. Chief complaint

4. Present illness
The …

5. Present illness
The …

6. Present illness
The …

7. Present illness
The …

8. Present illness
The …

9. Present illness
The …

10. Present illness
The …

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

12. 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(-),

13. 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

14. 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─┼x┼─ ─┼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

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

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

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

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

19. NE – motor function

20. Lab data

21. Lab data

22. Available image MR

23. Different diagnosis
r/o

24. Tentative Diagnosis