神经系统病历.docVIP

Case record Name handed ：（L）or (R) Sex: Date of admission Age Informant Race Nationality Marital status Reliability Occupation Address Chief complaint Present history Past history Personal history Family history Physical examination Vital signs BP P T R General appearance: Consciousness development nutrition Facial features mental status Skin: color, edema or dehydration, subcutaneous node, ulcer , scar and hair Lymphonodes: Skull: shape, head perimeter , percussion Auscultation, scalp sense organs of head : eye , ear and mastoid process, nose and accessory sinuses tenderness, pharynx, tonsil, dental caries , lingual surface Neck: movement thyroid gland trachea carotid artery peripheral artery Chest: shape heart: HR cardiac borerline auscutation lung: percussion auscutation Abdomen: degree of hardness tenderness tumor ascitic fluid Liver spleen Vertebral column: shape , tenderness, motility Extremities: shape motility of joints Anus: Exterior genitalia: Meningeal irritation sign: neck rigity Kernig sign Lassegue sign: left right Neurological examination Mental Status: Cognitive Function： Examination of the Cranial Nerves I smell: left right II visual acuity: left right fundus oculi Visual field III, IV ,VI ptosis of upper lid: left right Eye ball protrusion or invagination location of eyeball pupils: left mm right mm shape light reflex: direct:left right indirect: left right accommodation reflex: left right movement nystagmus diplopia V sensation: left right coreal reflex lower mandible moveme