case 2

Case 2 - History taking (CNS)

History taking script

·         Personal details

o   65 year old

o   Male

o   Government servant (retired 5 years ago)

o   Married with 2 children

·         PC

o   - his left body is stiff, and not moving according to his will -

o   since 2 days ago.

·         HPC

o   2 days ago, had the worst headache ever on the right side of his head at 7pm

o   Vomited 3 times after that

o   Took aspirin and slept it off

o   Next morning felt dizzy - and his left body was limp

o   Completely unable to move his left side of body now.

o   Left side of body feels numb as well.

·         PMH

o   Diagnosed of Polycystic Kidneys at age of 40. - on regular checkup

o   Diagnosed of DM2 at age of 50 - on medication

o   Diagnosed of Hypertension at age 53. - on medication

·         Family history

o   Father died at age of 70 - from diabetes foot infection

o   Mother died at age of 76  - she had hypertension, stroke 4 years before death and bedridden - died of pneumonia

·         Social history

o   Drinks 1 can of beer every night - 2 in the weekend since 25

o   Non-smoker now

o   Smoked for 30 years since 23 to 53, 1 packet / day.

o   No exercise hobbies - sedentary lifestyle

·         worries

o   he is afraid he will be bedridden like his mother

o   why afraid ? - don’t want to be a  burden to his family - would rather die.

Question variation 1

1.       ask…

a.       PC

b.      HPC

c.       PMH

2.       Questions

a.       How old is he? (1m)

b.      What was his occupation? (1m)

c.       What is his presenting complaint? (2m)

d.      Elaborate on his history of presenting complaint (6m)

e.      Elaborate on the past medical history (5m)

f.        What is his probable diagnosis? (2m) state 3 risk factors. (3m)

Question variation 2

1.       Ask…

a.       PC

b.      HPC

c.       Family history

2.       Questions

a.       What is his presenting complaint? (2m)

b.      Elaborate on his history of presenting complaint (6m)

c.       Elaborate on the family history (4m)

d.      What is his probable diagnosis? (2m)

e.      state 3 risk factors. (3m)

f.        from his symptoms, where is the lesion in the brain? Be specific. (2m)

                                                               i.      right cerebral hemisphere hemorrhage infarct due to ruptured artery of the middle meningial artery

possible PE case related to this case

man had SubArachnoid Haemorrhage.

1.       Examine his lower limbs - emphasis on motor functions

a.       Inspections

b.      Palpation

c.       Movements

d.      Power

e.      Deep tendon reflexes

2.       Viva - state whether you would expect a UMN lesion / LMN lesion in this case

What are the differences of UMN/LMN lesions?