Words in Capital represent words inserted by the lecturer/guide.
Age : 50
Address: Parit Jawa, Johor
Occupation : Palm Oil plantation worker
Date of Admissiom:10th April 2006
 
Chief Complaint: Sudden paralysis from the hip and below since 6 th April 2006
 
History of Presenting Complaints:
 
He was cycling on Thursday morning at 7 am when he suddenly fell from the bicycle .He then realized that he could not move both his legs from the hip and below and he could not feel that his legs were on the ground.The paralysis did not progress or regress .
For the past one week , he has been having numbness and tingling on the back .
Two days before the paralysis , he had retention of urine and faeces.
In the morning of the attack, he had transient blurring of vision.
 
Negative history: No loss of consciousness, no headache , no nausea , no vomiting
 
Family history: No diabetes mellitus, hypertension, bronchial asthma, ischaemic heart disease, stroke , paralysis. Father had underwent a surgery to alleviate the the problem of decreased   micturition.
 
Treatment history: taking medication for a mental illness{ according to the doctor he has schizophrenia, do I say schizophrenia or just say mental illness}
 
Medical history: no previous hospitalization or surgery . No drug allergy
 
Social history: Not married. Stays alone at home. Mom has passed away and dad is staying with stepmother in Selangor.Has 2 elder sisters and one elder brother which have not kept in touch for at least 5 years.
 
Personal History: Smokes tobacco from the age of 12 until present , 5 sticks a day. Diet is mixed. Sleep is disturbed , one hour of sleep everyday since the past five years. When he wakes up from his sleep in the morning, he just stares around. Unable to pass urine and faeces since two days before the paralysis until now. No weight loss or loss of appetitive.
 
 
General Examination
 50 year old patient is alert , not in distress, poorly built and poorly nourished.
 
Pallor : present
Icterus: none
Clubbing: Grade 1
Cyanosis: none
Lymadenopathy:none
Edema:none
 
Vital signs
 
Respiratory rate: 20
BP: 90/60 mm hg
Temp:37 degrees Celsius
Pulse: 72 . Normal volume,regular rhythm, no special character, no vessel wall thickening
 
Head to toe examination.
 
Head: No loss of hair. No dandruff. No thinning of hair
Mouth: Poor oral hygiene. Yellowish discoloration on teeth due to tobacco intake. Gums and tongue are pale. No coating on tongue. Uvula placed centrally. Posterior pharyngeal wall looks normal. dorsum surface of tongue looks normal.
Neck: Jugular venous pulse not seen. No lymph nodes palpable.
Axilla: no lymph nodes palpable
Hands:Pallor present. No muscle wasting. Clubbing grade 1 .
Spine: Centrally placed.
 
Central nervous system examination:
 
Higher mental functions:
 
Conscious: yes
Orientation: Time ….yes
                   Person….yes
                   Place…yes
Emotional state: Not in any emotional distress .comfortable
Delusion and hallucination: used to have auditory hallucination [stopped after medication for schizophrenia}
General intelligence: { what do I write in this column] level of education is till 5 th standard (You can write normal—education may not reflect intelligence)
Appearance: [what to fill in here]-Appeared normal to me
Behaviour: [what to fill in here}Well he was quite co-operative wasn't he. There wasn't anything odd in his behaviour that I recall
Memory: I have a problem in these section. I asked the patient a few questions. He knows which year is it, but he does not know the day ,date and month. He also does not know the name of the hospital where he is admitted. He also does not know the current prime minister of Malaysia.. Should I elaborate on short term and long term memory too
Speech; slurring of speech is present { should I mention if its dysarthria or aphasia]
HE HAS MILD DISORIENTATION TO TIME AND PLACE BUT ITS PROBABLY BECAUSE HE DOESN'T REALLY NEED TO KNOW THE DETAILS OF TIME AND PLACE. YOU SHOULD GET THE MINI MENTAL SCORING CARD PHOTOCOPIED FROM HUTCHINSON/HARRISON AND THEN THIS PART WILL BECOME EASIER AS THE STEPS TO GET THE INFO ON HIGHER MENTAL FUNCTION IS GIVEN IN THE FORM OF AN EASY QUESTIONNAIRE. DISTINGUISHING BETWEEN DYSARTHRIA AND APHASIA IS NECESSARY BUT CAN BE TRICKY. PUT IN SIMPLE TERMS DYSARTHRIA IS DIFFICULT, POORLY ARTICULATED SPEECH, SUCH AS SLURRING. APHASIA IS IMPAIRED EXPRESSION OR COMPREHENSION OF WRITTEN OR SPOKEN LANGUAGE.
 
Cranial Nerves:
 
I checked for all the cranial nerves and all are intact. When I write the complete report I will describe each one individually
 
Motor system:
Attitude: all the muscles are flexed . Patient is extending the all four limbs
Bulk:                                         right                                                         left
                Arm       8 inches in circumference                      8 inches in circumference
                              7.5 inches from acromion process          7.5 inches from acromion process
 
               Thigh    15.4 inches in circumference            14.5 inches in circumference
                              6 inches above patella                      6 inches above patella
 
            Lower leg   11.2 Inches in circumference             8.9 inches in circumference     
                                 5 inches below patella                     5 inches below patella
 
Tone: normal tone of muscles in the shoulder, arm and forearm
         Hypotonia in the muscles of hamstring , calf muscles, quadratus femoris
 
Power:                                           Right {grade]                        left [grade]
 
                Shoulder                                   
                                       
                Abduction                                 5                                      5
                Adduction                                 5                                      5
               Medial rotation                          5                                      5
               Lateral rotation                          5                                      5
               Extension                                   5                                      5
               Flexion                                       5                                      5
 
               Elbow                                 
 
              Flexion                                        5                                      5
              Extension                                    5                                      5
 
              Wrist
 
               Extension                                   5                                     5
               Flexion                                      5                                      5
 
                Hand grip                                 5                                     5
 
                 Hip
 
                 Extension                                      0                                  0
                 Flexion                                          0                                  0
                 Lateral rotation                             0                                  0
                 Medial rotation                             0                                  0
                 Abduction                                     0                                  0
                  Adduction                                     0                                  0
 
                  Knee
                                           Right [grade]                 left {grade}
Extension                                    0                                0
Flexion                                        0                                0
 
Ankle
 
Dorsiflexion                                0                                0
Plantar flexion                            0                                 0
Eversion                                     0                                  0
Inversion                                    0                                  0
 
 
Deep tendon relexes               right                              left
 
Biceps                                       2                                   2
Triceps                                      2                                   2
Supinator                                  2                                   2
Knee jerk                                  0                                   0
Ankle jerk                                 0                                   0
Plantar reflex                            0                                    0
 
Cerebellum
 
Finger nose test:normal
Heel sliding over shin: normal
Gait: not applicable
No rebound phenomenon
 
Sensory system
 
Touch : sensation lost below umbilicus
Pain: sensation lost below umbilicus
Temperature: not done
Pressure: not felt at Achilles tendon
Vibration sense: not felt at ball of great toe, medial malleolus, pattella and anterior superior iliac spine
Position sense: not applicable in lower limb, normal in upper limb
Sterognosis: normal
Graphesthesia: { I am not sure about this.. For example I drew the letter L on the patient's hand but he identified it as letter E.. I tested it on 2 different days. And still when I draw the letter L , patient says it's the letter E.   so should I mention its normal or mention the defect here} YES YOU CAN MENTION THIS AS NORMAL. IN HIS FINAL IMPRESSION WE AREN'T EXPECTING ANY CORTICAL LESION ISN'T IT.
Two point discrimination: not done

Spinchter;
 Loss of tone of bladder muscles and anal rectum
 
Sir. Do I need to describe about the large bedsore which I see on the left gluteal region in this examination as well
 
And do I need to include the mini mental state examination which is given in Hutchinson
 YES IF YOU INCLUDE THESE THEN IT SHALL BE MORE COMPLETE
Sir  , it's the first time I have done a detailed CNS case. So please tell me any correction or if I need to enter any other information.
 
I think that's my case for now. Please let me know about the corrections and I will tend to it right way.
 
ALSO, YOU OUGHT TO HAVE WRITTEN THE DIAGNOSIS WHICH IS CAUDA EQUINA SYNDROME (AS DISCUSSED). THE POINTS IN FAVOR ARE THE LMN LESION IN THE L5,S1 S2(FLACCID PARAPARESIS) S3 S4 SEGMENTS (SADDLE ANESTHESIA AND LOSS OF ANAL SPHINCTER TONE). ETIOLOGY COULD BE AS WE DISCUSSED EITHER PROLAPSED INTERVERTEBRAL DISCS OR SECONDARY METASTASES (YOU DIDN'T MENTION ANYTHING ABOUT BACK-PAIN IN HIS HISTORY WHICH IS ODD).