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二、Neurological examination

Mental status:

Consciousness: clear

Gcs:E4 , V4-5 , M6

Language: spontaneous speech (+)naming(+),comprehension (+),

Repetition(+)

Orientation(time/place/person):ok/ok/ok

Cranial nerves:

##CN-II.

Visual field: normal by confrontation test

Pupil size(R/L): 3.0mm/3.0mm

Light reflex(R/L): (+) / (+)

##CN-III,IV ,VI.

Ptosis(R/L): (-) / (-)

EOM: full

##CN-V.

Sensory-(V1/V2/V3): R’ t: ok/ok/ok

L’ t: ok/ok/ok

Motor-masseter m. (R/L): ok/ok

Cornea reflex(R/L): (+) / (+)

Jaw jerk: +

##CN-VII. No facial palsy

##CN-VIII.

Hearing: normal

Nystagmus:

##CN-IX,X.

#MP:

RUE distal grade 5-,LUE distal grade 5-

RUE proximal grade 5-,LUE proximal grade 5-

RUE proximal grade 5-,LLE proximal grade 5-

RUE distal grade 5-,LLE distal grade 5-

手術日期及方法

NIL.

住院治療經過

The patient was admitted to ward via ER under the impression of head injury

with forehead laceration. Lacerarion was suture at ER and after

admission, wound with gentamycin oint care QD+prn. Follow up C-spine x-ray and

rule out C2 fracture. So C-spine CT was performed and no fracture finding. The

general condition get stable and the headache subside gradually. The patient

was discharged in a improving and stable condition.

1 Answer

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  • 1 decade ago
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    二、Neurological examination神經學檢查

    Mental status:精神狀態

    Consciousness: clear意識清楚

    Gcs:E4 , V4-5 , M6昏迷指數 E4 V4-5 M6→課本有自己查這裡不想贅述

    Language: spontaneous speech (+)naming(+),comprehension (+),Repetition(+)語言:自述(+)命名(+)理解力(+)復頌(+)

    Orientation(time/place/person):ok/ok/ok 定向感(時/地/人)ok/ok/ok

    Cranial nerves:顱神經(測12對腦神經功能)

    ##CNI-II.第1-第2對

    Visual field: normal by confrontation test視野:正常

    Pupil size(R/L): 3.0mm/3.0mm瞳孔大小(左右) 3.0mm/3.0mm

    Light reflex(R/L): (+) / (+)對光反射(左/右)(+)/(+)

    ##CN-III,IV ,VI.第3.4.5對

    Ptosis(R/L): (-) / (-)下垂(左/右)(-)/(-)

    EOM: full外眼球肌:功能俱全

    ##CN-V.第5對

    Sensory-(V1/V2/V3): R’ t: ok/ok/ok

    L’ t: ok/ok/ok 感覺(左/右) ok/o/ok

    Motor-masseter m. (R/L): ok/ok運動(右/左)ok/ok

    Cornea reflex(R/L): (+) / (+)角膜反射(左/右)(+)/(+)

    Jaw jerk: +咀嚼肌 (+)

    ##CN-VII. No facial palsy第7對 顏面無麻痺

    ##CN-VIII.第8對

    Hearing: normal聽力正常

    Nystagmus:眼球震顫

    ##CN-IX,X.第9-10對

    #MP:肌力

    RUE distal grade 5-,LUE distal grade 5-右/左上肢末稍分數5

    RUE proximal grade 5-,LUE proximal(近心端) grade 5-

    RUE proximal grade 5-,LLE (左下肢)proximal grade 5-

    RUE distal grade 5-,LLE distal grade 5-

    手術日期及方法

    NIL.無

    住院治療經過

    The patient was admitted to ward via ER under the impression of head injurywith forehead laceration.

    這個病患因頭部外傷和前額撕裂傷經由急診送到病房來

    acerarion was suture at ER and aftera dmission, wound with gentamycin oint care QD+prn. Follow up C-spine x-ray and rule out C2 fracture. So C-spine CT was performed and no fracture finding.

    在急診時已做了縫合術,傷口用健它黴素軟膏一日換一次藥或需要時換藥.頸椎X光顯示疑似第2頸椎骨折,所以更進一步做了頸椎的電腦斷層掃瞄結果發現沒有骨折情形.

    The general condition get stable and the headache subside gradually. The patientwas discharged in a improving and stable condition.

    病患病情趨於穩定,而且頭痛的情況有日漸減緩的現象,所以基於此穩定且病況改善的條件下辦理出院..

    Source(s): 學護理的自己
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