Neurological status

PASSPORT PART

Full name Sick
Age:
Marital status:
Occupation:
Time of event:

COMPLAINTS

The weakness in the right hand, blockage of the right hand, the violation of the sensitivity pavoy hand and in the lower third of forearm. Also, the patient complains that his hand is hanging and he can not pick it up.

ANAMNESIS MORBI

According to the patient, after a drunk, asleep, leaning on the grid, when I woke up, found the appearance of the above symptoms.

Cerebral symptoms

Consciousness - a clear
Contact
Oriented in the environment
Meningeal symptoms - no

Cranial nerves

I. - Smell saved
II. - Without changing the
III. , IV, VI - The width of eye slits - the same on both sides
No ptosis
Strabismus is missing
Gaze paresis not
Movement of the eyeballs in full S = D
The width of the pupils the same on both sides
Anizokariya missing
Pupillary reflexes - saved S = D
Horner's syndrome - no
Arja-Robertson syndrome - no
V. - A). Sensitivity V nerve branches and zones Zeldera saved S = D
Sore points out there is no nerve V S = D
Trigger points are painless S = D
b). Voltage chewing muscles without deviation, no atrophy.
a.) Corneal reflexes saved S = D
Mandibular reflex save S = D
VII. - Symmetrical facial muscles - is proportional to both sides
Mimic the sample normal S = D
Superciliary reflex - saved S = D
VIII. - A). The severity of hearing - in the last year said hearing loss in the right ear
Tinnitus - sometimes in the right ear
b). Dizziness - no
Nystagmus - absent
In the Romberg stable
IX, X. - Ingestion - fully preserved
Phonation - normal. Phonation at soft palate is movable.
Oral automatism reflexes absent
Reflexes from the back of the throat and soft palate are not changed
XI. - Turns heads - normal
Shrug - normal S = D
Muscular strength - no change S = D
Atrophy - no
Fibrillation - no
XII. - Articulation - compromised by the absence of front teeth
Atrophy - no
Fibrillation - no
Tongue movement preserved in their entirety

Motor area
External examination: Atrophy - no
Fibrillation - no
Active movement: - marked paresis of the right hand (the inability extension brush, difficulty bending, the inability of fine movements of fingers, difficulty opposing thumb)
Passive movements: - marked hypotension, muscle hypotrophy right hand (m. flexor carpi radialis, m. Flexor pollicis, m opponens pollicis, m. Palmaris longus, m. Extensor carpi radialis, m. Extensor digitorum, mm. Extensor pollicis), that corresponds to zones innervation of radial and median nerves.
Motor coordination: Statics - saved
Gait: limping on his right leg due to injury
Paltsenosovaya and pyatochnokolennaya sample - saved
Intention - no
Dizmetriya - absent
Adiadohokinez - absent
Asynergy - absent
Hyperkinesis - no
Facial expression in normal

SENSITIVITY

Complaint. Observed violation of pain, temperature, tactile sensitivity in the lateral part of the wrist, the back surface of 1.2, the lateral three fingers, the palm of the hand.
Muscle-joint feeling in fingers, still retained
Complex kinds of sensitivity:
Stereognosis completely preserved S = D
Topognosia present
Two-dimensional spatial sense - saved S = D
Pain points without features
Symptoms of tension and nerve roots - negative

REFLEXES

Miostaticheskie
With the biceps tendon - Live S = D
With triceps tendon - Live S = D
Periosteum of the radius - Live S = D
Knee - Live S = D
Achilles - Live S = D
Skin
Abdominal
top - live S = D
medium - live S = D
bottom - living S = D
Plantar - live S = D
Pathological
Babinski - no
Oppenheim - no
Rossolimo - no
Tremnera - no

The pelvic organs

Control of the pelvic organs.

Higher nervous activity

Slurred speech, due to the lack of front teeth
Praxis, gnosis - have not changed.
Agraphia - absent
Account - normally
Memory - is not changed
Intelligence - the same level of development
Criticism to his condition - Adequate
Emotional sphere - normal

Topical diagnosis

Clinically detected evidence of non-robust peripheral paresis of radial and median nerves in the right hand, which is manifested in the motor and sensory disorders (extensor weakness of the right hand, the weakness of the flexor wrist and fingers, malnutrition tenor difficulty opposing thumb, reduction of pain, temperature, tactile sensitivity on the lateral part of the wrist, the back surface of the 1, 2, lateral part of the three fingers, the palm of the hand.

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Direct inguinal hernia on the right

III. Anamnesis morbi: considers herself a patient in March 19, 2003, when, during physical activity first appeared bulging tumor (about the size of a walnut) in the right groin, painful, accompanied by abdominal pain, cutting character. The patient took a horizontal position, and soon the pain subsided independently, bulging right, health care is not addressed. Patient notes that: 1) further education increased (there) with little physical exertion, coughing, straining, passing in a vertical position, which was accompanied by pain in the abdomen and education itself, in the transition to a horizontal position - education disappeared, the pain abated, and 2) maximum (when standing) dimensions of education gradually increased. Nausea, vomiting, belching, bloating, constipation during this period of time denied. The emergence of significant discomfort, limitations in work sick decided to go to the clinic X number of X (05/02/03 g), which was examined by the surgeon and diagnosed with an inguinal hernia on the right hospitalized in the 1st surgical unit X for X number of additional tests and appropriate treatment.

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Scheme history of psychiatry

I. Passport information patient: Surname, first name
Date of birth
Home Address
Job
Profession
Who sent, the date of admission to hospital
Diagnosis on admission:

II. Complaints:

If the patient complains, it is necessary to briefly describe their specific content.

III. Life history (according to patient):

1. Heredity.
2. Preschool: behaviors in the team, favorite games especially education: rigor, despotic parents would apply their sentences; raised alone or in a large family. Relationships with parents, sisters and brothers.
3. The period of study at the school, college, college. Ability, academic performance, interests and hobbies.
4. Work activity, profession. The respective interests of the profession. Attitude. Relationships at work. How often and for what reasons to change jobs.
5. Military service.
6. Sexual development and sexuality. Menstruation, their origin, regularity, being during menstruation. Marriage. Relation to the spouse. Sexual conflicts. Pregnancy, childbirth.
7. Past medical history (in chronological order). You should also find out - how patient tolerates heat, cold, variations in atmospheric pressure.

IV. History of present illness:

To find out what immediately preceded this mental illness, what were the first signs of the disease, when and by whom they are marked and how the dynamics of disease progression. Circumstances and causes of hospitalization. For patients with recurrent income (exacerbation) need to figure out catamnesis - mental health after discharge, the type of outpatient treatment, health status at the time efficiency.

V. Physical examination:

Appearance, his age appropriate. Condition of the skin. Musculoskeletal system. Bodies of circulatory, respiratory, pischevareniya.VI. Neurological research. VII. Mental status: The state of consciousness: the orientation in place and time, of the self. Availability Contact: fully accessible, selectively, not available.
Appearance (neat, sloppy, etc.) and the manner of behavior: the situation adequately, friendly, unfriendly, passive, negative, etc.
Sensation and perception: senestopatii, hallucinations, and other violations of their content.
Attention: sustainable, indirect, Further distracting.
Memory - to describe the violations of memory.
Intelligence: a wealth of knowledge, the ability to recharge them and use them,
Interests of the patient. A critical evaluation of the condition. Installations for the future.
Thinking: the rate of flow of associations (slow, fast). Describe the type of thought disorder: thoroughness, fragmentation, etc. Identified obsessions and delusions, their nature, content. Emotional sphere: mood - adequate situation, lower high. Signs of depression (sadness, anxiety, fear, and the presence of suicidal thoughts), euphoria, dysphoria, emotional stupidity. Motor-volitional: calm, relaxed, excited, motor stalled. Various kinds of excitement and stupor, pathological vlecheniy.VIII. Laboratory and special methods: Blood (general, blood sugar, clotting, RW, HIV, etc.).
Urinalysis.
Fecal (in dysentery group glistonositelstvo etc.).
Radiographic issedovaniya.
ECG
EEG

IX. Diary of Supervision.

X. Diagnosis and its rationale.

XI. Recommended treatment.

Recommendations on discharge.

Forecast.

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