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RADIOLOGY INTERACTIVE CASE

Guys, hindi ako sure dun sa salient features.. Pacheck na lang.. Patanggal na lang nung sa tingin niyo di kailangan at padagdag nung tingin niyo dapat nakasulat. Tnx! . RADIOLOGY INTERACTIVE CASE. GROUP 10

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RADIOLOGY INTERACTIVE CASE

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  1. Guys, hindi ako sure dun sa salient features.. Pacheck na lang.. Patanggal na lang nung sa tingin niyo di kailangan at padagdag nung tingin niyo dapat nakasulat. Tnx! 

  2. RADIOLOGY INTERACTIVE CASE GROUP 10 Onggoco R., Ordoveza, M., Pacquing, P., Paderna, N., Padolina, D. Pagkalinawan, L., Palacpac, K., Palisoc, M., Palma, S.

  3. HISTORY OF PRESENT ILLNESS 2007 (+) frontal headache PAS 7-8/10 temporarily relieved by Paracetamol January 2008 (+) frontal headache > left side (+) forgetful, irritable April 2008 (+) difficulty in ambulation

  4. (+) sudden stiffening of her all extremities • (+) upward rolling eyeballs for 5 minutes. • (+) loss of consciousness  • Consult and admission  May 14, 2008

  5. REVIEW OF SYSTEMS No weight loss No cough, dyspnea, shortness of breath, hemoptysis No palpitataons, easy fatigability, orthopnea or syncope No bleeding tendencies

  6. PAST MEDICAL HISTORY (+) hypertension (+) diabetes mellitus (+) s/p TAHBSO for myoma uteri (1995) No history of heart disease, asthma or allergies

  7. PERSONAL AND SOCIAL HISTORY Non-smoker Non-Alcoholic beverage drinker No history of illicit drug use No exposure to industrial chemicals

  8. FAMILY HISTORY (+) Hypertension-father (+) Diabetes-mother (+) asthma-Mother (+) seizure disorder-aunt (-) Heart disease (-) Stroke (-) Connective tissue diseases (-) Cancer

  9. OB AND GYNE HISTORY Menarche: 10 years old Interval: 28-30 days Duration: 4 days Amount: 3 pads per day G5P5 (4204) s/p TAHBSO (1995) for myoma uteri

  10. PHYSICAL EXAMINTATION Conscious, coherent, not in cardio-respiratory distress BP 120/80 mmHg PR/CR: 88 bpm,regular RR 20 cpm T 37C Wt: 68 kgs Ht: 1.46 m BMI: 31.9 Warm, moist skin, no active lesion Pink palpebral conjunctivae, anicteric sclerae No nasoaural discharge Non-hyperemic external auditory canal, intact tympanic membrane

  11. Supple neck, no neck mass, no palpable lymphadenopathies, no carotid bruit Symmetrical chest expansion, no retractions, clear breath sounds Adynamic precordium, AB 5th LICS MCL, no murmurs Flat abdomen, normoactive bowel sounds, soft, non tender Pulses full and equal, no cyanosis and no edema

  12. Conscious, coherent, oriented to time, place, person, follow commands, can recall most of the recent and remote memories, no aphasia, no agraphesthesia, no apraxia, no right-left disorientation MMSE: 23/30

  13. (+) anosmia, L>R Pupils 2-3mm ERTL, (+) direct and consensual reflex Visual acuity: a20/20, OU; no visual field cuts Funduscopy: (+) ROR, no hemorrhages, (+) papilledema, OU Extraocular muscle full and equal, no nystagmus

  14. V1, V2, V3 intact, can clench teeth No facial asymmetry Intact gross hearing, no lateralization on Weber’s; Rinne’s AU: AC>BC (+) Gag reflex, bilateral; uvula midline Able to shrug shoulders and turn head side to side against resisitance Tongue midline on protrusion

  15. Motor: No atrophy, good tone on all extremities, no fasciculations, no spasticity, no rigidity MMT: 5/5 upper extremities (R & L) 4/5 (R) lower extremity 5/5 (L) lower extremety Sensory: light touch and pain, position, 2-point discrimination and vibration sense are intact Reflexes ++ on both upper and lower extremities

  16. (-) Hoffman’s reflex (-) Babinski No nuchal rigidity (+) Palmomental reflex (+) Snout reflex

  17. SALIENT FEATURES • Frontal Headache • (+) forgetfulness and irritable • Difficulty in ambulation • (+) sudden stiffening of her all extremities • (+) upward rolling eyeballs for 5 minutes. • (+) loss of consciousness  • (+) Hypertension andDM? • No exposure to industrial chemicals • MMSE: 23/30 • (+) anosmia, L>R • (+) papilledema on fundoscopy

  18. (-) Hoffman’s reflex • (-) Babinski • (+) Palmomental reflex • (+) Snout reflex

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