神經內科標準病歷範本
I. Cerebral vascular accident
Present Illness:
A man aged 62 had sudden left arm and leg weakness and slurred speech. Except
for untreated hypertension, his medical history was unremarkable. He is a smoker
with a 45 pack-year smoking history. On arrival at the emergency department 1 hour
15 minutes after the symptom onset, he reported no headache or vomiting. His blood
pressure was 180/100 mm Hg; his pulse, 76 beats/min and regular.
Neurologic examination examined dysarthria, a left homonymous hemianopia,
severe left-sided weakness; bilateral palpation, no left sided body response (left tactile
extinction).
Ⅱ. Seizure
Present Illness:
This man aged 70 had 2-year R’t cerebral infarction with mild left hemiparesis but
lived independently. His wife witnessed that he had left arm seizures after four-limb
convulsions for about 2 minutes with upward gaze, trismus and grimacing with
cyanosis. After the seizing, he effortfully breathed and was unresponseive to others’
voice until the ambulance arrived in about 8 minutes.
Ⅲ. Foot drop
Present Illness:
A 35-year-old man without systemic diseases visited our neurologic clinic because
the intermittent right lower leg tonic posture, following clonic twitching 1 minute,
occurred several times since September 2001. Resultanltly, the right leg weakness
lasted for several minutes. One week prior to an outpatient clinic relentless right foot
weakness was observed.
The neurologic examination evinced intact mentality, cranial nerves and sensory
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function. The four-limb muscle strength was normal except right ankle dorsiflexion
weakness which was Medical Research Council-rated 4. The deep tendon reflex,
representing the ankle jerk, was symmetric; bilateral plantar flexion, perceived by
eliciting the plantar reflex. He could walk over to the right on his tiptoes but not on
his heels.
Ⅳ. Diplopia and blurred vision
Present Illness:
This man aged 54 years and of blurred vision, dizziness, and visual defects two
months before admission experienced double vision, headache, and photophobia one
month later despite our neurologic outpatient department-prescribed medications.
The patient was neurologically indicated impaired left visual acuity, left
conjunctival chemosis, left eyelid swelling, left eye proptosis, and complete
oculomotor palsy, and left trochlear and abducens nerves. His pupils exposed isocoria.
The visual fields were full. The sensation was slightly trimmed in the left trigeminal
nerve ophthalmic branch. The left corneal response was marred, consistent with a left
trigeminal nerve abnormality. There were no: facial palsy; hearing impairment;
tinnitus; dysphagia; uvula and tongue deviation.
Ⅴ. Headache
Present Illness:
A 32-year-old woman without migraine or other chronic headache history until
two weeks prior to the admission accounted nausea- and vomiting- accompanied
intermittent severe throbbing headache in her bilateral occipito-temporal regions,
beside the headache intensity often increasing upon awakening, bending forward or
abdominal straining. There was no photophobia, phonophobia, tinnitus, monocular or
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binocular visual loss, dilopia, fever, orthostatic edema, neck stiffness, arthralgia, or
ataxia or other focal neurologic symptom. This patient took regular medication and
had no relevant medical history except danazol 600 mg taken daily for endometriosis
6 months ago and most notably discontinued 20 days prior to admission.
Ⅵ. Progressive dysarthria and dysphagia
Present Illness:
The 47-year-old non-diabetic of nasopharyngeal carcinoma (NPC) 20 years ago
received complete cobalt radiotherapy and experienced no recurrence. About 6
months prior to admission, the persistent deep-seated headache over the right
frontotemporal and maxillary regions happened; so did subsequently progressive
dysarthria and dysphagia. The serial examinations by otolaryngologists averred a
thickened posterior pharyngeal wall; The biopsy, only chronic inflammation. No
culture was acquired at that time. One week prior to admission, the left hemiparesis
suddenly started.
On the examination, he was alert and reported a distressing headache. The blood
pressure and body temperature were normal. The multiple cranial nerve lesions were
manifested. There were right eye ptosis and miosis. His dysarthric speech was with a
nasal tone. His dysphagia was severe; naso-gastric tube, for feeding. A plain
protuberant posterior pharyngeal wall was perceived. The right side gag reflexes were
spoiled and the right posterior tongue sensation was lost. The tongue deviated to the
right when extended. No external auditory canal granulation tissue was avowed.
Ⅶ. Motor neuron disease
Present Illness:
This computer-programming engineer aged 37 years denied any systemic disease
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or previous regular medications. He noted intermittent face and bilateral arms
twitching in recent 3 years and an insidious onset leg weakness exacerbated in recent
one year causing difficulty climbing stairs.
Occasionally, he also felt both posterior thigh numbness and prolonged
speaking-stimulated nasal tones. These symptoms did not occur at a particular timing
or show a diurnal change. They developed insidiously but appeared aggravated
increasingly, so he came to our hospital for check up.
Ⅷ. CNS infection
Present Illness:
The Taiwanese man aged 30 who studied in Berlin, Germany and had five day
fever and generalized weakness visited our infectious disease clinic. Laboratory data
(complete blood count with differential and chemical analysis) and urinalysis were
within normal limits, and so was chest X-ray. He was admitted to the infectious
disease ward next day. Ceftriaxone, broad-spectrum coverage for suspected
salmonellosis, was started.
Fever (peak, roughly 38.5°C) with dizziness, vomiting, and neck stiffness waxed and
waned during the initial hospital days.
Ⅸ. Diabetic cranial neuropathies
Present Illness:
A woman aged 56 years suffered acute onset left eye ptosis and binocular double
vision. Her past DM for five years without known hypertension or hyperlipidemia was
notable. Meanwhile, she ingested antihyperglycemic agents and had fasting sugar
from 100 to 250 mg/dl. Over the past two years the two transient facial palsy
episodes occurred bilaterally, respectively. Additionally, she was once hospitalized
for right eye similar ptosis events two months prior to this admission. Paresis over the
right medial rectus, superior rectus, and inferior rectus, and equivocally reduced
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pinprick sensation over the right ophthalmic nerve were recorded. The right
oculomotor nerve palsy was diagnosed, which completely resolved one month later.
Ⅹ. Unilateral Paresthesia
Present Illness:
A non-vegetarian aged 74 years with past significant hypertension and diabetes
mellitus presented with acute onset right face, arm and leg numbness and tingling.
The unilateral paresthesia persisted one day before medical consultation sought.
On admission, she was alert and oriented and without fever, meningismus,
headache, or head injury signs. Blood pressure was 154/86 mmHg. Neurological
examination and basic laboratory test results were unremarkable.
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