N.Chittemma.pptxXaXSDCSdcsckhjitduritkgWDFKJ
- 1. Name-N.Chittemma Age- 52/F Mrd no- 1348322 Diagnosis S/P Right FTP Decompressive craniectomy for right FTP contusion with midline shift Comorbiditirs-Nil
- 2. h/o Right FTP Decompressive craniectomy for right FTP contusion with midline shift on 4/3/24. Came for cranioplasty No fresh complaints
- 3. O/E: Patient conscious and coherent Vitals stable -CNS examination Higher mental function-normal
- 4. CRANIAL NERVE EXAMINATION CN 1: B/L sense of smell normal CN2: VA right 6/6 and left 6/6 CN 3,4,6- EOM full range No nystagmus No ptosis Pupils- B/L 3mm equal and reactive.
- 5. CN 5- Normal CN 7- Intact CN 8 B/L AC>BC , Weber's not lateralised CN 9, 10 Uvula midline Palatal movements normal ,no asymmetry
- 6. CN 11 Shoulder shrugging Normal on both sides CN 12 No fasciculations of tongue no Tongue deviation
- 7. Sensory examination: Normal Romberg's sign: Negative Tandem gait: Normal Cerebellar Examination: Normal Involuntary movements: No Meningeal signs: no
- 8. MOTOR SYSTEM: Tone Normal in both upper and lower limbs Bulk Normal in both upper and lower limbs
- 9. Power - right left Upper limb Shoulder- 4+/5 4+/5 Elbow- 4+/5 4+/5 Wrist- 4+/5 4+/5 Lower limb Hip- 4+/5 4+/5 Knee- 4+/5 4+/5 Ankle- 4+/5 4+/5 EHL- 4+/5 4+/5 Reflexes Superficial reflexes-present DTR: BJ TJ S KJ AJ Right - 2+ 2+ 2+ 2+ 2+ Left - 2+ 2+ 2+ 2+ 2+ Plantars- both flexors