Case presentation

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 …

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 0 0 0 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

Available image MR

Different diagnosis r/o

Tentative Diagnosis

Case presentation

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