jc grandcase im pe-course-progress

7/27/2019 JC GrandCase IM PE-Course-Progress

1/24

PHYSICAL EXAMINATION

GENERAL SURVEYPatient was examined awake, conscious, coherent, and cooperative. He was oriented to time,

place and person. He was afebrile, non-ambulatory, and not in respiratory distress. He had an ongoing IVline hooked at .

VITAL SIGNS!lood Pressure " #$%&'% mmHgHeart (ate " ') beats&min(espiratory (ate " *+ cycles&minemperature " $. /0, left axillaHeight "

1ctual 2eight " !3I " I!2 "

SKINInspection

4kin is brown

5o 6aundice, cyanosis, bruises5o rashes, scars

Palpation4kin is warm7ood skin turgur5o signs of tenderness7ood capillary refill 89999 seconds:

HEENTHead

Inspection4kull is normocephalic and atraumatic

Hair is black, moderate in amount and evenly distributed4calp has no flakes and lice observed;ace is symmetrical with no involuntary movements

Palpation5o signs of tenderness5o lump or lesion

EyesInspection


2/24

EarsInspection

4ymmetrical auricles with no lesions5o signs dishargesPearly gray tympanic membrane and 8=: cerumen on both ears

Palpation5o signs of tenderness in auricular, external ear canal and mastoid area

1ble to hear whispered and spoken words on both ears

NoseInspection

5o alar flaring, discharges and swellingPink turbinates4eptum midline

Palpation5o signs of tenderness

Mouth and ThroatInspection

>ips are pinkish, dry, with no lesions

?ral mucosa and gums are pinkish with no redness, bleeding or ulcerationongue is midline@vula is deviated to the rightonsils not swollenIntact gag reflex

Ne!Inspection

4upple neck5ot distended neck veins

Palpationhyroid glands and lymph nodes non palpable

rachea midline5o tenderness and masses

CHEST AN" LUNGS1nterior

Inspection4ymmetrical chest5o retractions and deformities

Palpation$ in the left

Percussion(esonant on both lung fields

1uscultationVesicular breath sounds on both lung fields8-: rhonchi and rales8-: wheeBing


3/24

CAR"IOVASCULARInspection

1dynamic precordiumPalpation

1pex beat palpable CthI048-: heavesD 8-: thrills

PercussionEullness at *ndto $rdI04

1uscultation(egular heart rate and irregular rhythmEistinct 4# and 4*4$ and 4) not heard5o murmurs

A#"OMENInspection

;lat, no lesions, pulsations, and visible veins5o visible peristalsis

1uscultation

5ormoactive bowel sound at ' clicks per minutePercussion

ympanitic in most of the Auadrants>iver span" cm 30>D ) cm 34>

PalpationPain upon light and deep palpation in the (@F and (>F5on-palpable spleen and liver

GENITOURINARYInspection

5o lesions, masses, and dischargesPalpation

0ostovertebral angle tenderness

8=: kidney punch in the right

MUSCULOSKELETALInspection

5o deformities, atrophies, and 6oint swellingPalpation

5o signs of 6oint tenderness3anipulation

7ood range of motion in the upper extremities@nable to move both lower extremities

PERIPHERAL VASCULAR SYSTEM

!rachial (adia

l

;emoral Popliteal Eorsalis Pedis Posterior ibial

(ight *= *= - *= *= *=

>eft *= *= - *= *= *=


4/24

NEUROLOGIC EXAMINATION

I$ Cere%ru&3ental 4tate

0onscious

!ehavior

8-: 3annerisms

8-: (estlessness

3ood and 1ffect

1ppropriate mood and affect

4peech

1ble to articulate with clear and moderate loud voice

Perceptions

?rganiBed and coherent with good 6udgment throughout the interview

0ognitive

?riented to time, person and placeII$ Cere%e''u&

0oordinated movements

5o tremors

8-: gait ataxia

8-: pronator drift, 8-: (oombergGs sign

III$ Men(n)ea' S()n

8-: !rudBinski sign, 8-: ernig sign

IV$ Cran(a' Ner*esI. 1ble to smell coffee on both nostrils

II. 1ble to see and identify letters&words at a distance of # meterIII, IV, VI. Intact extraocular musclesV. 3otor" Intact temporal and masseter muscles 4ensory" 1ble to identify light touch on the forehead, cheeks and mandibular area

8=: corneal reflexVII. 1ble to wrinkle forehead, frown, smile, show teeth and close both eyesVIII. able to hear spoken and whispered voice on both earsI, . 8-: dysphagia, 8-: dysarthia, 8=: gag reflexI. 1ble to shrug shoulders against resistance

1ble to turn head on both sides against resistanceII. 1ble to protrude and move the tongue from side to side without deviation


5/24

V$ Sensory

Pa(n Te&+erature V(%rat(on L()ht Touh

L, (ight = = = =

>eft = = = =L- (ight - = = =

>eft - = = =

L. (ight - = = -

>eft - = = -

L/ (ight - = = -

Le0t - = = -

L1 (ight - = = -

>eft - = = -

S, (ight - - = -

>eft - - = -

S- (ight - = -

>eft - = -

VI$ Motor

!iceps riceps Iliopsoas 7luteus Fuadriceps Hamstring1nkle

flexor andextensor

(ight C&C C&C %&C %&C %&C %&C C&C

>eft C&C C&C %&C %&C %&C %&C C&C

VII$ "ee+ Tendon and Su+er0((a' Re0'e2es

!iceps riceps !rachoradialis nee 1nkle

(ight

>eft


6/24

COURSE IN THE 3AR" 45u'y ,-6 -7,78 ,stday o0 ad&(ss(on9

?n the day of admission, patient was afebrile, with paralysis of the lower extremities associatedwith lower back pain lasting for one week. he vital signs were as follows" blood pressure J #*%&+%mmHg, pulse rate J * beats per minute, respiratory rate J # cycles per minute, temperature J $+.$ 0.>aboratory examination ordered were 0!0, 5a, , 0a, 0reatinine, 1lkaline phosphate, chest x-ray 8P1view:, ultrasound of kidney, urinalysis and ray of lumbar spine 81P>:. Initial working impression for thepatientGs condition was herniated disc. He was given Vit. ! complex taken in the morning and evening,combi-pack of ) regimens 8IsoniaBid Cmg&kg, (ifampin #%&kg, PyraBenamide *%-*C mg&kg and(: at $% gtts&min and had a foley bag catheter draining to a urobag.

@rinalysis result" color of urine was yellowD transparency- haByHematology result" !lood type K?LD (h=, >eukocytosisD ungs clear, heart not enlarged, rest unremarkable. 5egative chest

findings.horacolumbar spine, 1P> result" PottGs disease with paravertebral abscess, #%-##.

4pondylosis, lumbar spine

?n the *ndday of admission, patient was afebrile, still with paralysis of the lower extremities associatedwith lower back pain. he vital signs were as follows" blood pressure J #$%&+% mmHg, pulse rate J %beats per minute, respiratory rate J *+ cycles per minute, temperature J $+.) 0. 3edications werecontinued. Patient was hooked in IV fluid 8P544: at $% gtts&min.

!lood chemistry result" 4erum 0reatinine %. mg&d> 8normal:D1lkaline phosphatase ** I@&> 8elevated:

idney ultrasound result" !oth kidneys are normal in siBe. here are no masses within renalparenchyma. he central echogenic complex is distinct. hecorticomedullary 6unctions are ill defined. he pelvocalyceal system andproximal ureters are not dilated. he pararenal spaces are unremarkable.

@rinary bladder is well filled with urine. he walls are not thickened.Prostate gland is normal in siBe. 5o calcifications noted.Impression" Pyelonephritic changes both kidneys.

?n the $rdday of admission, patient was afebrile, still with paralysis of the lower extremitiesassociated with lower back pain. he vital signs were as follows" blood pressure J #*%&+% mmHg, pulserate J 'C beats per minute, respiratory rate J $$ cycles per minute, temperature J $+.) 0. 3edicationswere continued. Patient was still hooked in IV fluid 8P544: at $% gtts&min.

?n the )thday of admission, patient was afebrile, still with paralysis of the lower extremitiesassociated with lower back pain. he vital signs were as follows" blood pressure J #*%&'% mmHg, pulserate J ' beats per minute, respiratory rate J $* cycles per minute, temperature J $+.# 0. 3edicationswere continued. (eAuest was made for referral with a neurologist.

?n the Cthday of admission, patient was afebrile, still with paralysis of the lower extremitiesassociated with lower back pain. he vital signs were as follows" blood pressure J #*%&+% mmHg, pulserate J % beats per minute, respiratory rate J *+ cycles per minute, temperature J $+.* 0. 3edicationswere continued. Patient was hooked in IV fluid 8P544: at $% gtts&min.

?n the thday of admission, patient was afebrile, still with paralysis of the lower extremitiesassociated with lower back pain. he vital signs were as follows" blood pressure J #$%&'% mmHg, pulserate J % beats per minute, respiratory rate J $C cycles per minute, temperature J $+.# 0. 3edicationswere continued. Patient was still hooked in IV fluid 8P544: at $% gtts&min.


7/24

8aug. #':?n the +thday of admission, patient was afebrile, still with paralysis of the lowerextremities associated with lower back pain. he vital signs were as follows" blood pressure J #$%&'%mmHg, pulse rate J ''beats per minute, respiratory rate J * cycles per minute, temperature J $+.* 0.3edications were continued. Patient was still hooked in IV fluid 8P544: at $% gtts&min.

8aAug. #:?n the 'th day of admission, patient was afebrile, still with paralysis of the lowerextremities associated with lower back pain. he vital signs were as follows" blood pressure J #*%&'%mmHg, pulse rate J '% beats per minute, respiratory rate J ** cycles per minute, temperature J $.C0.He was given Vitamin ! taken once a day, per orem and other medications were continued. Patient wasstill hooked in IV fluid 8P544: at $% gtts&min. (eAuest was made for physical therapy including arms andfeet electrical stimulation.

8aug. *%:?n the th day of admission, patient was afebrile, still with paralysis of the lowerextremities associated with lower back pain. he vital signs were as follows" blood pressure J #*%&+%mmHg, pulse rate J '%beats per minute, respiratory rate J *) cycles per minute, temperature J $+.C 0.3edications were continued. Patient was still hooked in IV fluid 8P544: at $% gtts&min.

8aug. *#: ?n the #%thday of admission, patient was afebrile, still with paralysis of the lowerextremities associated with lower back pain. he vital signs were as follows" blood pressure J #*%&'%

mmHg, pulse rate J #%% beats per minute, respiratory rate J * cycles per minute, temperature J $+.)0.3edications were continued. Patient was still hooked in IV fluid 8P544: at $% gtts&min.;oley bag catheter was removed in the morning and reinserted in the afternoon.

8aug. **: ?n the ##thday of admission, patient was afebrile, still with paralysis of the lowerextremities associated with lower back pain. he vital signs were as follows" blood pressure J #*%&'%mmHg, pulse rate J '' beats per minute, respiratory rate J * cycles per minute, temperature J $+.C 0.3edications were continued. Patient was still hooked in IV fluid 8P544: at $% gtts&min. (eAuest wasmade to start bladder training.

8aug. *$: ?n the #*thday of admission, patient was afebrile, still with paralysis of the lowerextremities associated with lower back pain. he vital signs were as follows" blood pressure J #*%&'%mmHg, pulse rate J % beats per minute, respiratory rate J *' cycles per minute, temperature J $. 0.

3edications were continued. Patient was still hooked in IV fluid 8P544: at $% gtts&min.

8aug. *): ?n the #$thday of admission, patient was afebrile, still with paralysis of the lowerextremities associated with lower back pain. he vital signs were as follows" blood pressure J #*%&+%mmHg, pulse rate J ' beats per minute, respiratory rate J *) cycles per minute, temperature J $+.* 0.3edications were continued. Patient was still hooked in IV fluid 8P544: at $% gtts&min.

8aug *C: ?n the #) th day of admission, patient was afebrile, still with paralysis of the lowerextremities associated with lower back pain. he vital signs were as follows" blood pressure J #*%&'%mmHg, pulse rate J '% beats per minute, respiratory rate J *) cycles per minute, temperature J $.' 0.3edications were continued. Patient was still hooked in IV fluid 8P544: at $% gtts&min. (eAuest wasmade to remove foley bag catheter.

8aug. *: ?n the #Cth

day of admission,patient was afebrile, still with paralysis of the lowerextremities associated with lower back pain. he vital signs were as follows" blood pressure J #$%&'%mmHg, pulse rate J '* beats per minute, respiratory rate J * cycles per minute, temperature J $. 0.;ollowing reAuests were made" transfer to watcherGs area, refer to ! unit for ! medications, informrehab unit for continuation of physical therapy and home medications" Vitamin ! 0omplex !IE P.?. and0alcium >actate !IE P.?.


8/24

Pro%'e& L(st:

"ate Entered No$ At(*e Pro%'e&s "ate o0 Onset "ateReso'*ed

Inat(*e;Reso'*ed Pro%'e&s

I&+ress(on" PottGs Eisease

Sa'(ent eft flank paino 5umbness on both hips

o ;ever and profuse sweating

o >oss of appetite

o 2eight loss

o >ower extremity paralysis

Phys(a' E2a&(nat(on:o 0ostovertebral tenderness

o yphosis

o 5o pain sensation on ># and >*

o 5o pain sensation and light touch on >$-4#

o 5o pain sensation on 4*

o Hyperreflexia

o Presence of 0lonus and !abinski sign

o >ower extremity paralysis


9/24

"(00erent(a' "(a)nos(s"

"(00erent(a' Ru'e In Ru'e Out

(@F pain 8 : 5umbness on both hips

2eakness on lowerextremity

Phys(a' E2a&(nat(on:

>ower back pain

Paralysis of the lowerextremities

Impairment of bowel andbladder function.

>ack of some sensationsin lower extremities

Hypereflexia

Presence of 0lonus and!abinski reflex

In(dene:

0ommon in males$rd-Cthdecades of life

H(story:

5o family history of cancer 5o fever and profuse

sweating

Phys(a' E2a&(nat(on

5o lymphadenopathy

La%oartory Resu'ts:

-ray shows no calcificationin the thoracic disc 8:nalimot ko sa itsura satoxray

>ow


10/24

3otor 4ymptoms

Paralysis or paresis of

the lower limb

Increasing weakness and

stiffness of the lower limb!ladder Involvement

@rgency of micturition 3ild nocturia

incontinence

4pinal 0ord 4ymptoms

Eegree of spactic

paraparesis withincreased tone in bothlower extremities

!ilateral ankle clonus

>hermitteGs 4ign

;lexion of the head may

result in an electric-likeshock passing down thespine and down to thelimbs

;atiguePain

Eysesthetic most

commonly in the lowerlimb

0hronic pain in girdle-

like around the wait ofabdomen, as low backpain

Pain on eye movement

@nilateral headache

5o cerebellar symptoms

remors

Eysarthria

runcal ataxia

>imb ataxia5o brainstem symptoms

Eiplopia

;acial weakness

Eysarthria

Eysphagia

5o memory deficits and dementia5o sexual dysfunction5o seiBures

7uillain-!arre 4yndrome


11/24

Pro)ress Notes

"ay , 45u'y -/6 -7,79

Pro%'e& =,: Ina%('(ty to stand =-: R()ht U++er >uadrant Pa(n =.: Lo? %a! +a(n on %oth s(des =/: "ysur(a

#$ V(ta' S()nso !.P J #*%&'% mmHg 8 left arm: HeightJ

o P.( J +* beats&min. 2eightJ

o (.(. J *) cycles&min. !3I J

o emperature" $ /0 I!2J

C$ S!(n and S!(n a++enda)es:Ins+et(on:

o brown skin

o no edema, no cyanosis

o no clubbing of nails

o no lesions, sores, ulcers, rash, petechia

o no pallor, 6aundice

Pa'+at(on:o capillary refill" N # sec.

o good skin turgor

o skin is warm and moist

o no tenderness, pain

"$ HeadIns+et(on:

o no nits, flakes, dandruff and lice

o hair is evenly distributed, smooth, dry and black in color

o no lumps, lesions

o face is symmetrical and no involuntary movements

Pa'+at(on:o head is normocephalic and atraumatic

o head is tender

o no lesions, rashes, edema and tenderness on the face

E$ EyesIns+et(on:

o pale con6unctivaeo anicteric sclera

o no ptosis, nystagmus

o no opacities

o no lid lag

o no excessive tearing

o positive for (?(

o all extraocular movements are intact

o good visual acuity


12/24


13/24

o regular rhythm

o no visible carotid pulsations

o no deviation of the sternum

Pa'+at(on:o no palpable thrills O heaves

o no tenderness

o apex beat at Cth

I04 30>Ausu'tat(on:

o no murmurs were noted

o regular heart rate and rhythm

o distinct s# O 4*

K$ Chest and 'un)sIns+et(on:

o no intercostals retractions

o symmetrical with no chest deformities

o no lesions

Pa'+at(on:o no tenderness or masses

o eAual chest expansiono eAual intensity of tactile fremitus on all lung fields

Peruss(on:o resonant on all lung fields

Ausu'tat(on:o no rales, ronchi, wheeBes

o vesicular breath sounds heard all over lung fields

L$ A%do&enIns+et(on:

o globular and soft

o absence of abdominal distention

o no visible veins6 no visible pulsations

o no hyperpigmentation

o umbilicus is in the midline with absence of hernias

o no lesions

Ausu'tat(on:o normoactive bowel sound with #C bowel sounds for # min.

o no bruits heard

Peruss(on:o tympanitic in all Auadrants

o dull liver with a liver span of cm on 30> and ) cm on 34>

Pa'+at(on:o tenderness on the (@F upon light and deep palpation

o spleen not palpable

o absence of abnormal pulsationso no masses

o costovertebral tenderness

o negative fluid wave test

o no palpable thrills

M$ Musu'os!e'eta'Ins+et(on:

o no deformities


14/24

o no edema

o no redness or swelling of 6oints

Pa'+at(on:o no tenderness of muscle or 6oints

Ran)e o0 &ot(on:o impaired range of motion below the umbilicus

N $ Neuro'o)(,$ Menta' status

o oriented to time, place and person

o conscious and coherent

o can remember past and recent events

o answers Auestion in an spontaneous and moderate manner or pace

o able to follow instructions

o responds to stimuli simultaneously and appropriately

-$ Cere%ru&o !ehavior" no mannerisms and no restlessness

o 4peech" articulate words and sentences in moderate pace and loudness

o 3ood and affect are appropriate with topics under discussion

o Perceptions are organiBed and coherent with good 6udgement throughout the interviewo 0ognitive" oriented to time, place and person

.$ Cere%e''ar 0unt(ono unable to stand

o no tremors

o can perform finger-to-nose test

/$ Cran(a' ner*es

I: able to identify powdered coffee on both nostrils 8no anosmia:

II: good visual acuityo pupils reactive to both direct and indirect light reflex

III6 IV6 VI: no ptosiso all extraocular movements are intact

V: patient can open and close her mouth

o 4ensory" able to identify light touch O pain sensations on all divisions 8 e.x. forehead,

cheeks and mandibular area:o Positive corneal reflex on both eyes

VII: able to wrinkle, show teeth, frown, smile and close both eyes without facial deviation

VIII: able to hear whispered words on both ears

IX: able to swallow saliva : positive for gag reflex

X: able to speak and talk clearly without difficulty : positive for gag reflex : uvula not deviated

XI: unable to shrug shoulders with resistance : patient was able to turn head on the left side but unable to turn her head on the right

side XII: able to protrude tongue and move it from side to side

a$ Motor o unable to assess gait

o symmetric muscle bulk

o hypotonic on both lower leg

o strength

;lexion of left armJ C&C


15/24

;lexion of right armJ )&C

*Jno pain sensation

Intact light touch, vibration>$Jno light touch, pain sensation

Intact temperature and vibration>)Jno pain and light touch

Intact temperature and vibration>CJno pain and light touch

Intact temperature and vibration4#Jno pain and light touch

Intact temperature and vibration4*Jno pain sensation

Intact light touch, temperature and vibration4$Junable to assess4)Junable to assess

o able to identify ob6ects by touching them with closed eyes

8steorognosis:

Eermatome Pain emperature >ight ouch Vibration&position

>#>eft - = = =

(ight - = = =

>*>eft - = = =

(ight - = = =

>$>eft - = - =

(ight - = - =

>)>eft - = - =

(ight - = - =

>C>eft - = =

(ight - = =

4#>eft

(ight

$ Re0'e2o Pectoralis reflex Jpresent on both sides


16/24

o !abinski is present on the left foot but absent on the right foot

o 0lonus is present on both lower extremities

riceps !iceps !rachioradialis nee 1nkle

(ight #= #= *= *= % 8 :

>eft #= #= #= *= % 8 :

Assess&ent:Impression"Eifferential Eiagnosis"

P'ans:Eiagnostics

Pharmacologic"ru) Ty+e "osa)e

5on-pharmacologic


17/24

"ay - 45u'y -16 -7,79

Su%@et(*e:Patient complained of pain in lower back, lower Auadrant abdomen and on catheter.

Patient also noted tingling sensations on the right and left lower extremitiesO%@et(*e:

Patient was examined awake, conscious, coherent and bed ridden.V(ta' S()ns:

#P: #$%&% mmHg 8supine, right arm:HR: $ bpm 8supine, radial pulse:RR: $* cpmTe&+: $.Co0 8right axilla:

Neuro'o)(enderness was noted on the lower Auadrant of the abdomen.Menta'status" patient was cooperative and non-irritable.

!ehavior" no mannerism and restlessness 4peech" articulate with moderate pace and loudness

3ood and affect" appropriate topics under discussion Perception"organiBed and coherent with good 6udgment

throughout interview 0ognitive" oriented to time and place

Cran(a'Ner*es"I able to smell with both nostrilsII pupils unreactive to direct and consensual light reflex 5o light perception on both eyesIII 5egative papillary light reflex for both direct and consensual papillary

constrictionIV intact extraocular movementsV able to clench teeth with good strengthD intact sensations to pain and

temperature

VI eyes were able to move in all directionsVII able to smileD no facial asymmetryVIII good hearing acuityI positive for gag reflexD soft palate rises symmetrically positive for gag reflexD soft palate rises symmetricallyI no shoulder lagII no tongue deviation and protrusion


18/24

Sensat(on"1ble to respond to vibration on lower extremities@nable to respond to pain and temperature lower extremities, particularly

on the right and left >C dermatome and right 4# and 4*

dermatomes@nable determine *-point discrimination on right and left dermatome

>),>C, 4# and 4*1ble to identify ob6ects by touching them with closed eyesPositive number identification


>#>eft =

(ight =

>*>eft =

(ight =

>$>eft =

(ight =

>)>eft =

(ight =

>C>eft =

(ight - - =

4#>eft =

(ight - - =

Cere%e''ar"@nable to asses coordinated movements" finger to nose, heel to shin8-: truncal ataxia8-: tremors8-: nystagmus

Motor"@nable to asses gait4ymmetric muscle gait8-: atrophy8-: fasciculationIncrease muscle tone4trength"

;lexion 8>eft arm:" C&C;lexion 8(ight arm:" C&C


19/24


20/24

Pro)ress Notes"ay . 45u'y -B6 -7,79

Su%@et(*e:

Patient is still unable to stand. Paralysis and numb sensation on both lower extremities. ;lank painpersistent on both sides below the costovertebral angle. Hypogastric Pain and dysuria present.

O%@et(*e:GENERAL SURVEY:

Patient was examined awake, conscious, coherent, and cooperative. He was oriented totime, place and person. He is calm and relaxed. He was afebrile, non-ambulatory, and not incardiac and respiratory distress. He prefers to lie in a supine position. 5o movements on thelower extremities and active movement on upper extremities.

VITAL SIGNS:

!lood Pressure" #*%&'%Heart (ate&Pulse (ate" + bpm

(espiratory (ate" *) cycles&memperature" $. 0

PERTINENT PHYSICAL EXAMINATION >F, (>F and hypogastric area 8*%:. 5o reboundtenderness. 5egative fluid wave test, >iver and 4pleen are not palpable. 5o rigidity on abdominalwall. 5egative murphyGs sign. 5o shifting dullness. >eft and right costovertebral tenderness withleft side 8*%: more painful than the right. >ower flank pain on left side 8*%: and right side8C%:.

5


21/24

NEUROLOGIC EXAMINATION

I$ Cere%ru&3ental 4tate" Patient is awake, consciousness, responsive and coherent!ehavior" no mannerisms3ood and 1ffect" appropriate affect4peech" good and clear articulationPerceptions" good perspective on life0ognitive" oriented to time, person and place

II$ CERE#ELLUM3ovements are coordinated. gait ataxia not tested. pronator drift not tested. (oombergGs sign nottested. 0an do rapid alternating movements. Point to point discrimination intact.

III$ CRANIAL NERVESI. can smell on both nostrilsII. cannot see and identify letters&words at a distance of # feetIII, IV, VI. extraocular muscles, accommodation reflex, convergence intact

V. 3otor" temporal and masseter muscles intact4ensory" light touch on the forehead, cheeks and mandibular area

corneal reflex intactVII. can wrinkle forehead, frown, smile, show teeth and close both eyesVIII. can hear spoken and whispered voice on both earsI, . dysphagia and dysarthia with gag reflex intactI. can shrug shoulders against resistance

0an turn head on both sides against resistanceII. can protrude and move the tongue from side to side without deviation

IV$ SENSORY5umber identification intact, 4tereognosis intact, two point discrimination intact and pointlocaliBation intact on both sides of the body. actile sensation intact at 0* 0 and #-#*.


>#>eft - = =

(ight - = =

>*>eft = = =

(ight - = =

>$>eft - = - =

(ight = = = =

>)>eft - = - =

(ight = = - =

>C>eft - = -

(ight = = =

4#

>eft - = = =

(ight - = = =

V$ MOTOR 41;194upine body position. 5o involuntary movements, 3uscle bulk is poor on lower extremities and

good on upper extremities, 3uscle tone is poor on lower extremities and good on upper extremities.

!iceps riceps Iliopsoas 7luteus Fuadriceps Hamstring 1nkleflexor and


22/24

extensor

(ight C&C C&C %&C %&C %&C %&C %&C

>eft C&C C&C %&C %&C %&C %&C %&C

VII$ "EEP TEN"ON AN" SUPER


23/24

"ay / 45u'y -6 -7,79

Pro%'e&:initial impression

Su%@et(*e: Paralysis of lower extremities8Hypogastric pain C%D Eysuria #%:

O%@et(*e:

Vital 4igns!lood Pressure" #$%&%Heart (ate" '* beats&minute(espiratory rate" # cycles&minuteemperature" $.0

Physical


24/24

Assess&ent:Patient was able to sit with support for C minutes. Pain of #%% severity felt at the lowerback region when attempting to sit.

Impression"Eifferential Eiagnosis"

P'ans:Eiagnostics

Pharmacologic

"ru) Ty+e "osa)e

5on-pharmacologic

jc grandcase im pe-course-progress

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