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PHYSICAL EXAMINATION GENERAL SURVEY Patient 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 IV line hooked at . VITAL SIGNS !lood Pressure " #$%&'% mmHg Heart (ate " ') beats&min (espiratory (ate " *+ cycles&min ,emperature " $-.. /0, left axilla Height " 1ctual 2eight " !3I " I!2 " SKIN Inspection 4kin is brown 5o 6aundice, cyanosis, bruises 5o rashes, scars Palpation 4kin is warm 7ood skin turgur 5o signs of tenderness 7ood capillary refill 89999 seconds: HEENT Head Inspection 4kull is normocephalic and atraumatic Hair is black, moderate in amount and evenly distributed 4calp has no flakes and lice observed ;ace is symmetrical with no involuntary movements Palpation 5o signs of tenderness 5o lump or lesion Eyes Inspection <yebrows and eyelashes are symmetrical <yelids able to close fully 5o lid lag and ptosis Pale bulbar and palpebral con6uctivae 1nicteric sclerae 5o opacities and discharges 5one strabismus Pupils constricting from ) mm to * mm 1ble to move in - cardinal directions Intact corneal reflex on both eyes 8=: red orange reflex both eyes

Ears Inspection 4ymmetrical auricles with no lesions 5o signs disharges Pearly gray tympanic membrane and 8=: cerumen on both ears Palpation 5o signs of tenderness in auricular, external ear canal and mastoid area 1ble to hear whispered and spoken words on both ears Nose Inspection 5o alar flaring, discharges and swelling Pink turbinates 4eptum midline Palpation 5o signs of tenderness Mouth and Throat Inspection >ips are pinkish, dry, with no lesions ?ral mucosa and gums are pinkish with no redness, bleeding or ulceration ,ongue is midline @vula is deviated to the right ,onsils not swollen Intact gag reflex Ne ! Inspection 4upple neck 5ot distended neck veins Palpation ,hyroid glands and lymph nodes non palpable ,rachea midline 5o tenderness and masses

CHEST AN" LUNGS 1nterior Inspection 4ymmetrical chest 5o retractions and deformities Palpation <Aual chest expansion with no lagging <Aual tactile fremitus in both lung fields Pain in costovertebral angle 8=: numbness at paraspinal >* and >$ in the left Percussion (esonant on both lung fields 1uscultation Vesicular breath sounds on both lung fields 8-: rhonchi and rales 8-: wheeBing

CAR"IOVASCULAR Inspection 1dynamic precordium Palpation 1pex beat palpable Cth I04 8-: heavesD 8-: thrills Percussion Eullness at *nd to $rd I04 1uscultation (egular heart rate and irregular rhythm Eistinct 4# and 4* 4$ and 4) not heard 5o murmurs A#"OMEN Inspection ;lat, no lesions, pulsations, and visible veins 5o visible peristalsis 1uscultation 5ormoactive bowel sound at ' clicks per minute Percussion ,ympanitic in most of the Auadrants >iver span" - cm 30>D ) cm 34> Palpation Pain upon light and deep palpation in the (@F and (>F 5on-palpable spleen and liver GENITOURINARY Inspection 5o lesions, masses, and discharges Palpation 0ostovertebral angle tenderness 8=: kidney punch in the right MUSCULOSKELETAL Inspection 5o deformities, atrophies, and 6oint swelling Palpation 5o signs of 6oint tenderness 3anipulation 7ood range of motion in the upper extremities @nable to move both lower extremities PERIPHERAL VASCULAR SYSTEM !rachial (adia ;emoral l (ight *= *= >eft *= *= Popliteal *= *= Eorsalis Pedis *= *= Posterior ,ibial *= *=

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 place II$ 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-: Hernig sign IV$ Cran(a' Ner*es I. 1ble to smell coffee on both nostrils II. 1ble to see and identify letters&words at a distance of # meter III, IV, VI. Intact extraocular muscles V. 3otor" Intact temporal and masseter muscles 4ensory" 1ble to identify light touch on the forehead, cheeks and mandibular area 8=: corneal reflex VII. 1ble to wrinkle forehead, frown, smile, show teeth and close both eyes VIII. able to hear spoken and whispered voice on both ears II, I. 8-: dysphagia, 8-: dysarthia, 8=: gag reflex II. 1ble to shrug shoulders against resistance 1ble to turn head on both sides against resistance III. 1ble to protrude and move the tongue from side to side without deviation

V$ Sensory L, LL. L/ L1 S, S(ight >eft (ight >eft (ight >eft (ight Le0t (ight >eft (ight >eft (ight >eft Pa(n = = Te&+erature = = = = = = = = = = V(%rat(on = = = = = = = = = = = = = = L()ht Tou h = = = = 1nkle flexor and extensor C&C C&C

VI$ Motor !iceps (ight >eft C&C C&C ,riceps C&C C&C Iliopsoas %&C %&C 7luteus %&C %&C Fuadriceps %&C %&C Hamstring %&C %&C

VII$ "ee+ Tendon and Su+er0( (a' Re0'e2es !iceps ,riceps !rachoradialis (ight >eft

Hnee

1nkle

COURSE IN THE 3AR" 45u'y ,-6 -7,78 ,st day o0 ad&(ss(on9 ?n the day of admission, patient was afebrile, with paralysis of the lower extremities associated with 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, H, 0a, 0reatinine, 1lkaline phosphate, chest x-ray 8P1 view:, ultrasound of kidney, urinalysis and Iray of lumbar spine 81P>:. Initial working impression for the patientGs 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 <thambutol #C-*% mg&kg: taken before breakfast once a day, and captopril *C mg every after meal. Patient was hooked in IV fluid 8EC>(: at $% gtts&min and had a foley bag catheter draining to a urobag. @rinalysis result" color of urine was yellowD transparency- haBy Hematology result" !lood type K?LD (h=, >eukocytosisD <osinophils +&#%% !lood chemistry result" decreased sodiumD slightly decreased 0alciumD normal Potassium 0hest 8P1 view: I-ray result" >ungs clear, heart not enlarged, rest unremarkable. 5egative chest findings. ,horacolumbar spine, 1P> result" PottGs disease with paravertebral abscess, ,#%-,##. 4pondylosis, lumbar spine ?n the *nd day of admission, patient was afebrile, still with paralysis of the lower extremities associated with lower back pain. ,he vital signs were as follows" blood pressure J #$%&+% mmHg, pulse rate J .% beats per minute, respiratory rate J *+ cycles per minute, temperature J $+.) 0. 3edications were continued. Patient was hooked in IV fluid 8P544: at $% gtts&min. !lood chemistry result" 4erum 0reatinine %.- mg&d> 8normal:D 1lkaline phosphatase **- I@&> 8elevated: Hidney ultrasound result" !oth kidneys are normal in siBe. ,here are no masses within renal parenchyma. ,he central echogenic complex is distinct. ,he corticomedullary 6unctions are ill defined. ,he pelvocalyceal system and proximal 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 $rd day of admission, patient was afebrile, still with paralysis of the lower extremities associated with lower back pain. ,he vital signs were as follows" blood pressure J #*%&+% mmHg, pulse rate J 'C 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. ?n the )th day of admission, patient was afebrile, still with paralysis of the lower extremities 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. (eAuest was made for referral with a neurologist. ?n the Cth day of admission, patient was afebrile, still with paralysis of the lower extremities 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 hooked in IV fluid 8P544: at $% gtts&min. ?n the -th day of admission, patient was afebrile, still with paralysis of the lower extremities associated with lower back pain. ,he vital signs were as follows" blood pressure J #$%&'% mmHg, pulse rate J .% beats per minute, respiratory rate J $C cycles per minute, temperature J $+.# 0. 3edications were continued. Patient was still hooked in IV fluid 8P544: at $% gtts&min.

8aug. #':?n the +th day of admission, patient was afebrile, still with paralysis of the lower extremities 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 lower extremities 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. He was given Vitamin !- taken once a day, per orem and other medications were continued. Patient was still hooked in IV fluid 8P544: at $% gtts&min. (eAuest was made for physical therapy including arms and feet electrical stimulation. 8aug. *%:?n the .th day of admission, patient was afebrile, still with paralysis of the lower extremities 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 #%th day of admission, patient was afebrile, still with paralysis of the lower extremities 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 ##th day of admission, patient was afebrile, still with paralysis of the lower extremities 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 $% gtts&min. (eAuest was made to start bladder training. 8aug. *$: ?n the #*th day of admission, patient was afebrile, still with paralysis of the lower extremities 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 $% gtts&min. 8aug. *): ?n the #$th day of admission, patient was afebrile, still with paralysis of the lower extremities 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 lower extremities 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 $% gtts&min. (eAuest was made to remove foley bag catheter. 8aug. *-: ?n the #Cth day of admission, patient was afebrile, still with paralysis of the lower extremities associated with lower back pain. ,he vital signs were as follows" blood pressure J #$%&'% 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, inform rehab unit for continuation of physical therapy and home medications" Vitamin ! 0omplex !IE P.?. and 0alcium >actate !IE P.?.

Pro%'e& L(st: "ate Entered No$ A t(*e Pro%'e&s "ate o0 Onset "ate Ina t(*e; Reso'*ed Reso'*ed Pro%'e&s

I&+ress(on" PottGs Eisease Sa'(ent <eatures: o (ight flank pain radiated to (@F exacerbated by bending and deep palpation o >eft flank pain o 5umbness on both hips o ;ever and profuse sweating o >oss of appetite o 2eight loss o >ower extremity paralysis Phys( o o o o o o o o a' E2a&(nat(on: 0ostovertebral tenderness Hyphosis 5o pain sensation on ># and >* 5o pain sensation and light touch on >$-4# 5o pain sensation on 4* Hyperreflexia Presence of 0lonus and !abinski sign >ower extremity paralysis

"(00erent(a' "(a)nos(s" "(00erent(a' <pidural 4pinal 0ord 0ompression 4econdary to ,umor Ru'e In H(story: ( and > (@F pain 8 : 5umbness on both hips 2eakness on lower extremity Phys( a' E2a&(nat(on: >ower back pain Paralysis of the lower extremities Impairment of bowel and bladder function. >ack of some sensations in lower extremities Hypereflexia Presence of 0lonus and !abinski reflex In (den e: 0ommon in males $rd-Cth decades of life 0ommon in young to middleaged adults 4udden onset of back pain !ilateral involvement 4phincter disturbance 8urinary retention: !ladder distention 4mooth and step-wise progression from days to weeks with stabiliBation at the peak of progression ;laccid paraparesis Eepressed or absent reflexes 4ensory deficit 8light touch, pain, temperature, position and vibration: ,he upper extent of the lesion is typically several segments above the level of the sensory loss >oss of sphincter tone 4ensory 4ymptoms 2eakness or paralysis Hypesthesia Paresthesia Eysesthesia Ru'e Out H(story: 5o family history of cancer 5o fever and profuse sweating Phys( a' E2a&(nat(on 5o lymphadenopathy La%oartory Resu'ts: I-ray shows no calcification in the thoracic disc 8 : nalimot ko sa itsura sato xray >ow <4( 8 : if high <4( suggestive of infection

,horacic ,ransverse 3yelitis

5o recent acute illness 5o upper respiratory tract illness 5o recent vaccinations 5o recent surgery Pain is usually in the intrascapular region Paresthesiae usually ascends from feet partial sensory deficit

Mcannot be ruled out completely by history and physical examination. Eiagnostic tests such as 0!0, 4pinal (adiograph, 3(I 8,*2I: and lumbar puncture are needed to rule out the differential.

3ultiple 4clerosis

5o motor 4ymtpms Progressive impairement of gait 5o visual symptoms Visual loss

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 with increased tone in both lower extremities !ilateral ankle clonus >hermitteGs 4ign ;lexion of the head may result in an electric-like shock passing down the spine and down to the limbs ;atigue Pain Eysesthetic most commonly in the lower limb 0hronic pain in girdlelike around the wait of abdomen, as low back pain 7uillain-!arre 4yndrome <lectrolyte Imbalance

Pain on eye movement @nilateral headache 5o cerebellar symptoms ,remors Eysarthria ,runcal ataxia >imb ataxia 5o brainstem symptoms Eiplopia ;acial weakness Eysarthria Eysphagia 5o memory deficits and dementia 5o sexual dysfunction 5o seiBures

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()ns o !.P J #*%&'% mmHg 8 left arm: o P.( J +* beats&min. o (.(. J *) cycles&min. o ,emperature" $- /0 C$ S!(n and S!(n a++enda)es: Ins+e t(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 "$ Head Ins+e t(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$ Eyes Ins+e t(on: o pale con6unctivae o 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 HeightJ 2eightJ !3I J I!2J

<$ Ears Ins+e t(on: o auricles are symmetrical o no lumps, lesions or deformities o both ear canals showed moderate ear wax o no discharges, foreign bodies and inflammation on both ears o auditory acuity" able to hear sounds& whispered voice on both ears o otoscopic exam. " eardrum J pearly white J no swelling, perforations, ulcerations J visible cone of light on both sides Pa'+at(on: o no tenderness and lumps G$ Nose and S(nuses Ins+e t(on: o no nasal obstruction or bleeding o nasal septum is in the midline o symmetric external nose o pinkish nasal mucosa o no nasal flaring o no nasal discharges o negative transillumination test Pa'+at(on: o no nasal & sinus tenderness H$ Throat and Mouth Ins+e t(on: o lips are purplish in color with moderate dryness o no ulcers o no lesions, patches or nodules it the oral mucosa o pinkish oral mucosa o gums are pinkish in color with no ulcers, bleeding or lesions o teeth are yellowish in color with dental caries o uvula is in the midline with no swellings and ulcers o pinkish tonsils and pharyngeal mucosa o tonsils not swollen o positive gag reflex I$ Ne ! Ins+e t(on: o trachea is in the midline o no masses and unusual pulsations o neck veins are not distended Pa'+at(on: o non-palpable thyroid gland and lymph nodes o no swelling, masses or lesions 5$ Card(o*as u'ar Ins+e t(on:

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> Aus u'tat(on: o no murmurs were noted o regular heart rate and rhythm o distinct s# O 4* K$ Chest and 'un)s Ins+e t(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 expansion o eAual intensity of tactile fremitus on all lung fields Per uss(on: o resonant on all lung fields Aus u'tat(on: o no rales, ronchi, wheeBes o vesicular breath sounds heard all over lung fields L$ A%do&en Ins+e t(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 Aus u'tat(on: o normoactive bowel sound with #C bowel sounds for # min. o no bruits heard Per uss(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 pulsations o no masses o costovertebral tenderness o negative fluid wave test o no palpable thrills M$ Mus u'os!e'eta' Ins+e t(on: o no deformities

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 interview o 0ognitive" oriented to time, place and person .$ Cere%e''ar 0un t(on o 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 acuity o pupils reactive to both direct and indirect light reflex III6 IV6 VI: no ptosis o 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

;lexion of right armJ )&C <xtension of upper extremitiesJ C&C ;lexion of lower extremitiesJ %&C <xtension of lower extremitiesJ %&C

%$ Sensory o 1ble to respond to light touch, pain, temperature and vibration from 0$-,#* >#Jno pain sensation Intact light touch, temperature and vibration >*Jno pain sensation Intact light touch, vibration >$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 vibration 4#Jno pain and light touch Intact temperature and vibration 4*Jno pain sensation Intact light touch, temperature and vibration 4$Junable to assess 4)Junable to assess o Eermatome ># >* >$ >) >C 4# >eft (ight >eft (ight >eft (ight >eft (ight >eft (ight >eft (ight able to identify ob6ects by touching them with closed eyes 8steorognosis: Pain ,emperature = = = = = = = = = = >ight ,ouch = = = = Vibration&position = = = = = = = = = =

$ Re0'e2 o Pectoralis reflex Jpresent on both sides

o o

!abinski is present on the left foot but absent on the right foot 0lonus is present on both lower extremities ,riceps #= #= !iceps #= #= !rachioradialis *= #= Hnee *= *= 1nkle %8 : %8 :

(ight >eft Assess&ent: Impression" Eifferential Eiagnosis" P'ans: Eiagnostics

Pharmacologic "ru)

Ty+e

"osa)e

5on-pharmacologic

"ay - 45u'y -16 -7,79 Su%@e t(*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 extremities O%@e t(*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: $* cpm Te&+: $-.Co 0 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 P able to smell with both nostrils II P pupils unreactive to direct and consensual light reflex 5o light perception on both eyes III P5egative papillary light reflex for both direct and consensual papillary constriction IV P intact extraocular movements V P able to clench teeth with good strengthD intact sensations to pain and temperature VI P eyes were able to move in all directions VII P able to smileD no facial asymmetry VIII P good hearing acuity II P positive for gag reflexD soft palate rises symmetrically I P positive for gag reflexD soft palate rises symmetrically II P no shoulder lag III P no tongue deviation and protrusion

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 eyes Positive number identification Eermatome ># >* >$ >) >C 4# >eft (ight >eft (ight >eft (ight >eft (ight >eft (ight >eft (ight Pain ,emperature >ight ,ouch Vibration&position = = = = = = = = = = = =

Cere%e''ar" @nable to asses coordinated movements" finger to nose, heel to shin 8-: truncal ataxia 8-: tremors 8-: nystagmus Motor" @nable to asses gait 4ymmetric muscle gait 8-: atrophy 8-: fasciculation Increase muscle tone 4trength" ;lexion 8>eft arm:" C&C ;lexion 8(ight arm:" C&C

<xtension 8@pper extremities:" C&C ;lexion 8>ower extremities:" %&C <xtension 8>ower extremities:" %&C

Reflexes:
R()ht Le0t #( e+s #= *= 8=: !abibski sign 8=: (ight clonus Tr( e+s #= #= #ra h(orad(a'(s #= #= A%do&en -A Pate''ar #= % A h(''es #= #= P'antar % %

Assess&ent: Impression" Eifferential Eiagnosis" P'ans: Eiagnostics

Pharmacologic "ru)

Ty+e

"osa)e

5on-pharmacologic

Pro)ress Notes "ay . 45u'y -B6 -7,79 Su%@e t(*e: Patient is still unable to stand. Paralysis and numb sensation on both lower extremities. ;lank pain persistent on both sides below the costovertebral angle. Hypogastric Pain and dysuria present. O%@e t(*e: GENERAL SURVEY: Patient was examined awake, conscious, coherent, and cooperative. He was oriented to time, place and person. He is calm and relaxed. He was afebrile, non-ambulatory, and not in cardiac and respiratory distress. He prefers to lie in a supine position. 5o movements on the lower extremities and active movement on upper extremities. VITAL SIGNS: !lood Pressure" Heart (ate&Pulse (ate" (espiratory (ate" ,emperature" #*%&'% +- bpm *) cycles&m $-.. 0

PERTINENT PHYSICAL EXAMINATION <IN"INGS: 1!E?3<5" Inspection" 1bdomen is flat in shape with definite contours. 5o abdominal distention noted. 5o changes in pigmentation. Eilated abdominal veins absent. @mbilicus is round, midline and everted. 1uscultation" !owel sounds at #- clicks per minute. !ruit absent on midline aorta, renal arteries, iliac arteries and femoral arteries. Percussion" 4light dullness of the left lower Auadrant and generally tymphanic in (@F, >@F and (>F. Palpation" Pain on deep palpation on >>F, (>F and hypogastric area 8*&#%:. 5o rebound tenderness. 5egative fluid wave test, >iver and 4pleen are not palpable. 5o rigidity on abdominal wall. 5egative murphyGs sign. 5o shifting dullness. >eft and right costovertebral tenderness with left side 8*&#%: more painful than the right. >ower flank pain on left side 8*&#%: and right side 8C&#%:. 5<(V?@4 4Q4,<3"

NEUROLOGIC EXAMINATION I$ Cere%ru& 3ental 4tate" Patient is awake, consciousness, responsive and coherent !ehavior" no mannerisms 3ood and 1ffect" appropriate affect 4peech" good and clear articulation Perceptions" good perspective on life 0ognitive" oriented to time, person and place II$ CERE#ELLUM 3ovements are coordinated. gait ataxia not tested. pronator drift not tested. (oombergGs sign not tested. 0an do rapid alternating movements. Point to point discrimination intact.

III$ CRANIAL NERVES I. can smell on both nostrils II. cannot see and identify letters&words at a distance of # feet III, IV, VI. extraocular muscles, accommodation reflex, convergence intact V. 3otor" temporal and masseter muscles intact 4ensory" light touch on the forehead, cheeks and mandibular area corneal reflex intact VII. can wrinkle forehead, frown, smile, show teeth and close both eyes VIII. can hear spoken and whispered voice on both ears II, I. dysphagia and dysarthia with gag reflex intact II. can shrug shoulders against resistance 0an turn head on both sides against resistance III. can protrude and move the tongue from side to side without deviation IV$ SENSORY 5umber identification intact, 4tereognosis intact, two point discrimination intact and point localiBation intact on both sides of the body. ,actile sensation intact at 0* P 0- and ,#-,#*. Eermatome ># >* >$ >) >C 4# >eft (ight >eft (ight >eft (ight >eft (ight >eft (ight >eft (ight Pain = = = = ,emperature = = = = = = = = = = = = >ight ,ouch = = = = = = = = Vibration&position

= = = = = =

V$ MOTOR 41;19 4upine 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 1nkle flexor and

(ight >eft

C&C C&C

C&C C&C

%&C %&C

%&C %&C

%&C %&C

%&C %&C

extensor %&C %&C

VII$ "EEP TEN"ON AN" SUPER<ICIAL RE<LEXES 476A,6 A-9 !iceps ,riceps !rachoradialis 1bdominal Hnee (ight % % % % =# >eft % % % % =# Positive clonus on both feet, negative for HernigGs and !rudBinkiGs 4ign Assess&ent: Impression" Eifferential Eiagnosis" P'ans: Eiagnostics

1nkle =# =*

!abinski 4ign = =

Pharmacologic "ru)

Ty+e

"osa)e

5on-pharmacologic

"ay / 45u'y -C6 -7,79 Pro%'e&: initial impression Su%@e t(*e: O%@e t(*e: Vital 4igns !lood Pressure" #$%&.% Heart (ate" '* beats&minute (espiratory rate" #. cycles&minute ,emperature" $-..0 Physical <xamination 3uscle strength" 4ensory Eermatome 0#-0' ,#-,* ># >* >$ >) >C 4# 4* (ight 5&1 5&1 = Pain >eft 5&1 5&1 = ,emperature (ight >eft 5&1 5&1 5&1 5&1 >ight touch (ight >eft = = = = = = = = Vibration (ight >eft 5&1 5&1 5&1 5&1 = = = = @pper extremities, )&C >ower extremities, %&C Paralysis of lower extremities 8Hypogastric pain C&#%D Eysuria #&#%:

8=: 0lonus at the left foot 8=: !abinski sign on both feet

Assess&ent: Patient was able to sit with support for C minutes. Pain of #%&#% severity felt at the lower back region when attempting to sit. Impression" Eifferential Eiagnosis" P'ans: Eiagnostics

Pharmacologic "ru)

Ty+e

"osa)e

5on-pharmacologic