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T.P.R. 42/F Right sided weakness

T.P.R. 42/F Right sided weakness. General Data. Theresa Rubala. 42 y.o ./Female. Right-handed. Cavite. Chief Complaint. Right-sided weakness. History of Present Illness. 8 Hours PTA (June 27, 2009). Woke up with numbness of R UE/LE. Progressed to weakness of R UE/LE .

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T.P.R. 42/F Right sided weakness

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  1. T.P.R. 42/FRight sided weakness

  2. General Data Theresa Rubala 42 y.o./Female Right-handed Cavite

  3. Chief Complaint Right-sided weakness

  4. History of Present Illness 8 Hours PTA (June 27, 2009) Woke up with numbness of R UE/LE Progressed to weakness of R UE/LE (+) dizziness/vertigo (+) high-pitched tinnitus Both ears (-) seizures, LOC, headache

  5. History of Present Illness On admission (+) right-sided weakness (-) headache (+) blurring of vision (-) diplopia (-) slurring of speech

  6. Review of Systems (-) easy bruisability (-) palpitations (-) hematuria (-) seizures (-) orthopnea (-) abdominal pain (-) hemoptysis (-) diarrhea (-) hematochezia (-) melena (-) vomiting (+) high pitched tinnitus (-) fever (-) headache (-) wt loss (-) anorexia (-) cough (-) colds (-) pallor (-) jaundice (-) rash (-) dyspnea (-) memory loss (-) nausea (+) BOV

  7. Past Medical History (-) Bronchial Asthma (-) Epilepsy (-) Diabetes Mellitus (-) CVD/CVA (-) Cancer (+) HTN

  8. Family Medical History (+) Asthma, mother (+) HTN, father (-) PTB (+) CA, uncle, lung (-) DM (+) CVA, father (-) Epilepsy (-) CVD

  9. Personal/Social History • (+) smoking, 2 sticks/day for 5 years • (-) alcohol • Day Care Center teacher, able to perform activities of daily living without any problem

  10. Living condition Bungalow House level with road Bathroom level with floor House is 10 m away from main road

  11. FIM – Self Care

  12. FIM – Sphincter Control

  13. FIM – Mobility

  14. FIM – Locomotion

  15. FIM – Communication

  16. FIM – Social Cognition

  17. Physical Examination

  18. General Survey Awake Conscious Coherent (-) Cardiorespiratory Distress

  19. General Survey Speaks in complete sentences and is oriented in the three spheres

  20. HEENT AnictericSclerae Pink Palpebral Conjunctivae Pupils (2-3mm) BRL

  21. HEENT No gross ear deformities No ear discharge Intact tympanic membrane No impaction Intact cone of light No hearing loss

  22. HEENT No nasal discharge No tonsillopharyngeal congestion Midline tongue No dental carries No oral ulcers

  23. HEENT No palpable cervical lymphadenopathy No tracheal deviation No anterior neck mass

  24. Chest Symmetric chest expansion No use of accessory muscles No retraction Equal Tactile Fremitus Resonant on percussion Clear breath sounds

  25. Heart Adynamicprecordium Regular rate Regular rhythm S2>S1 at the Base Apex Beat, 5th ICS MCL (-) Heaves, Thrills, Murmur

  26. Abdominal Exam Flat soft abdomen (-) Scars, spider nevus Normoactive bowel sounds (-) bruit (-) masses, tenderness Intact Traube’s space

  27. Genitourinary tract/DRE Genitalia not examined (-) costovertebral angle tenderness Digital Rectal Examination Intact perianal sensation Good Sphincter tone Intact rectal vault with feces Rectal wall smooth (-) voluntary contraction

  28. Skin and Extremeties (-) pallor (-) cyanosis (-) clubbing (-) nail deformities Good Skin Turgor Full Equal Pulses

  29. Neurologic Exam and MSE Awake Conscious Coherent Oriented to the 3 spheres

  30. Cranial Nerves

  31. CN I Intact

  32. CN II Pupils 2-3mm EBRTL (-) no visual field cuts

  33. CN III, IV, VII Preferrential gaze to the right (-) Ptosis

  34. CN V (+) corneal reflex intact light touch and pain sensation good masseter, pterygoids and temporalis tone

  35. CN VII Visible nasolabial folds symmetric smile good labial articulation

  36. CN VIII normal Weber’s and Rinne’s

  37. CN IX, X good and equal palatal elevation good guttural articulation equal gag reflex on both sides

  38. CN XI equal shoulder shrug

  39. CN XII good articulation no atrophy or fasciculation no tongue deviation

  40. Sensory Examination

  41. Sensory Examination

  42. Sensory Examination

  43. Sensory Examination

  44. Sensory Examination

  45. Motor Examination

  46. Motor Examination

  47. Motor Examination

  48. Motor Examination

  49. Motor Strength

  50. Motor Strength

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