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神經內科標準病歷範本-POMR
一、【POMR 範本】Acute ischemic stroke
2011/01/11 10:30 AM
S: L’t limbs weakness for 1 day
O: BP: 158/101 mmHg, HR: 87
Drowsy but arousable consciousness
Oriented to time/place/person
Able to obey commands
Light reflex: .2.0+/2.0+
Visual field: no deficit
Full EOM
Symmetric facial sensation
L’t central facial palsy
Dysarthria(+) and dysphagia(+) with NG insertion
Tongue protrusion: midline
Muscle tone: flaccid over L’t limbs
Muscle power: gr.2 over L’t upper and lower limbs, proximal=distal
DTR: +++ over L’t limbs, ++ over R’t limbs
Plantar response: extensor at L’t foot, flexor at R’t foot
Sensation: symmetric light touch and pinprick at both sides
F-N-F: L’t hand weakness, R’t hand: normal
Heel-knee-shin: L’t leg weakness, R’t leg: normal
Stance and gait: cannot do
Sphincter: normal urination and stool passage
Problem #1: L’t hemiparesis
A: R’t internal capsule posterior limb infarction, day2, no worsening of cognition and
muscle power, under Bokey 100mg 1# qd po and iv hydration of normal saline 60
ml/hr
P: Arrange brain CT, carotid duplex and brain MRI+MRA
Check lipid profiles
Antiplatelet agent and add statin if dyslipidemia
Explain the possible GI bleeding due to adverse effect of Bokey
Explain possible deterioation in the first 3 days of acute infarction
二、【POMR 範本】Guillain-Barré syndrome
2011/01/11 10:30 AM
S: double vision with four-limb weakness for 2 days
O:
BP: 128/83, HR:74
Clear consciousness and well-oriented
Right partial ptosis
EOM: paresis of the right medial rectus muscle
Facial diplegia
Weakness of the neck extensor especially in sitting position
Muscle power of four-limb was grade 3 in the proximal muscles and
grade 4 in the distal ones
DTR: generalized areflexia
Sensation: decreased pinprick sensation at the wrist and mid-leg area, and decreased
vibration sense on the fingers and toes
Problem #1: double vision with four-limb weakness
A: Acute quadriparesis with generalized areflexia and multiple cranial neuropathy,
suspected Guillain-Barré syndrome, in progression
P: Arrange emergent NCV
CSF study after brain CT
Start plasma exchange if Guillain-Barré syndrome was confirmed by laboratory studies
Inform the family the use of IVIG, which was not covered by the health insurance
Watch out for respiratory distress
三、【POMR 範本】Brown-Séquard syndrome
2011/01/11 10:30 AM
S: Right lower limb and trunk numbness for 4 days
O:
BP: 165/98, HR: 91
Clear consciousness and well-oriented
Left side miosis and ptosis
Full EOM without nystagmus
Symmetric facial expressions
No dysarthria or dysphagia
No tongue deviation
Left side hemiparesis: MP gr.3, equally in proximal and distal
Sensation: decreased pinprick sensation from the right lower limb to the trunk without
sacral sparing but preserved vibration sense, joint position sense
Sensory level at T5 on the right side
DTR: generalized hyporeflexia
Coordination: left limb dysmetria, left side deviation during sitting and walking
Sphincter function: intact
Problem #1: paresthesia in the right lower limb and trunk
A: Suspected left upper cervical spinal cord lesions, in progression
P: Arrange cervical and thoracic spinal cord MRI with contrast
Consult NS if there was a space occupying lesion
Arrange CSF study if no mass lesion
Arrange rehabilitation
Encourage the patient to do rehab to prevent disuse atrophy
四、【POMR 範本】Disturbed consciousness
2011/01/11 10:30 AM
S: unavailable
O:
Stuporous consciousness
Light reflex (direct/indirect) was impaired and the pupil size were 4.0 mm bilaterally
Skewed eye position and presence of ocular bobbing
Corneal reflex: -/Decreased gag reflex bilaterally
Vestibulo-oculocephalic reflex: -/Motor response: decerebrate posture on pain stimulation
DTR: +++ to ++++ over four limbs
Bilateral extensor plantar responses
Problem #1: Disturbed consciousness
A: Acute mental status changes, no improving
P:
Brain CT and CSF study
Laboratory workup for CBC, biochem, etc
Intensive monitoring of vital signs and neurologic status
Explain the possible causes and outcomes to the families.
五、【POMR 範本】Cheirobuccopedal Syndrome
2011/01/11 10:30 AM
S: Numbness confined to the left hand, foot and intraoral cheek
O:
BP: 150/85 mmHg, HR:85
Conscious and oriented
Visual field: no deficit
Full EOM
Facial, including mouth angle sensation: no deficit
Symmetrical facial expression
Full MP over four limbs
Sensation: a subjective 80% decrease of pinprick pain and 50% decrease of cotton
fine touch at left intraoral cheek, hand and foot; and 50% decrease of vibratory sense
at left hand and foot; positional joint sensation: no deficit
Corneal reflex: preserved
DTR: normoreflexia over four limbs
Coordination: normal
Steady gait
Problem #1: Abrupt onset of numbness confined to left hand, foot and intraoral cheek
A: Acute sensory deficit confined to the left hand, foot and intraoral cheek, suspected
CVA, active
P: Arrange brain CT, carotid duplex and brain MRI+MRA
Check lipid profiles
Antiplatelet agent and add statin if dyslipidemia
Explain the possible GI bleeding due to adverse effect of Bokey