Case present

Case presentation
Int:99.xx.xx

Name:GenderAgeChart 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 CVACADAsthma: 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 : fair to : fair to : 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 0x0 0x0 0 0 0 0 V: sensation: light touch: fair thermal: fair pin-prick: fair motor: massetertemporalis: fair V+VII: corneal reflex: fair VII: no facial palsyVIII:no hearing impairment

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

NE muscle tones and powers
Muscle tone: upper normal lower increasedMuscle 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