Case presentation 신경과 Pk15조 58번 이태영 76번 최병욱

Identifying Data Name : 김 O O Age : 82 Sex : female

Chief Complaint Lt. sided weakness and dysarthria for 2 hours

Present Illness 2007년 4월 10일 : 넘어져서 왼쪽 팔을 다친 후 LMC에서 입원치료.   2007년 4월 17일 : 오후 1시 30분경 병실에서 갑자기 말이 어둔해지고 왼쪽 팔, 다리에 힘이 빠져서 잘 움직이지 못하는 양상을 보이면서 본원 내원.

CXR : both lung hazziness abdominal gith : 72 cm hip girth : 80 cm Personal History Smoking (-)    Alcohol (-)  Occupation : 무직  Education : 무학 Rt. handedness Height : 150 cm Weight : 45  kg EKG : normal CXR : both lung hazziness abdominal gith : 72  cm hip girth : 80 cm BMI : 20 - 정상 허리/둔부 비 : 0.9 - 0.8이상이라 복부비만.

Pulmonary tuberculosis (-) Past History Hypertension (-)  Diabetes mellitus (-)  Pulmonary tuberculosis (-) Previous cerebraovascular accident history (-) Previous illness Hx    2006년 12월 SMA occlusion : 본원 혈관외과에서 OP. wafarin 1달 복용후 자의로 끊음

Family History Hypertension (-) Diabetes mellitus (-) Pulmonary tuberculosis (-) Cerebraovascular accident history (-)

System Review 특이사항 없음.

General appearance : Well developed Physical Examination Vital Sign      BP 150/90  mmHg   PR 88 회/min                    RR 20 회/min         BT 36.8'' C    General appearance : Well developed  

Neurologic Examination 1. Mental Status Consciousness level : drowsy (GCS=3+4+6=13) Speech : moderate dysarthria Memory Remote, recent, immediate : intact Time, place, person : intact

Neurologic Examination 2. Cranial Nerves I. Olfactory : unable to check due to poor coporation II.  V/A : unable to check due to poor coporation  V/F : Lt. homonimous hemianopsia Fundus : no papilledema & retinal change (-) III.IV.VI EOM : conjugate eyeball deviation to Rt.side Pupil : RRERL c 3mm Nystagmus : no spontaneous or gaze evoked nystagmus EOM : Both eyeball deviation to Rt. side

Neurologic Examination V. Facial sensation Pain, temperature Touch - intact Vibration VII. NLFF (-/+) Forehead wrinkling (+/+) Lt. central type facial palsy VIII.Hearing difficulty (-/-) Weber test : no lateralization Rinne test : (AC>BC, AC>BC) IX.X Gag reflex (+/+) Uvular deviation (-) XI. SCM & Trapezius muscle – Lt side weakness XII. Tongue deviation to Lt.side on protrusion

Neurologic Examination 3. Motor 1) Tone : normal 2) Power (5/5) (3/5) 3) Muscle bulk : no muscular atrophy 4. Sensory - decreased all sensory modalities on Lt. side Pain, temperature Touch Vibration, position (같다고 말을 하나 pain 을 주었을때 Lt.side 에서 pain 호소적음)

Neurologic Examination 5. DTR : Brachioradialis jerk (-/-) Biceps jerk(++/+++) Triceps jerk (-/-) Patella jerk (+/+) Ankle jerk (-/-) Babinski''s sign (-/-) 6. Cerebellar sign Finger to nose test : intact Heel to shin test : intact Romberg test : unable to check due to Lt. sided weakness Stepping gait : unable to check due to Lt. sided weakness Tandem gait : unable to check due to Lt. sided weakness 7. Gait : unable to check due to to Lt. sided weakness DTR : Brachioradialis jerk (-/-)              Biceps jerk(+/+)              Triceps jerk (-/-)               Patella jerk (+/+)               Ankle jerk (-/-)              Babinski''s sign (-/-)

Formulation Neurologic Examination상 Eyeball deviation to Rt. side Lt. homonimous hemianopsia Dysarthria Lt. central type 7 CN palsy Lt. hemiparesis Decreased all sensory modarlitis on Lt. side

Formulation 소견보이는 점 : Rt. Supratentorial 의 (Lt. facial palsy + Lt. hemiparesis) Corticospinal tract, Precentral gyrus (Lt. hemiparesis), Corticobulbar tract, Precentral gyrus (Lt. central type 7 CN palsy) Corticothalamic, Posterior white column tract, Thalamus, Postcentral gyrus (Decreased all sensory modarlitis on Lt. side) Optic tract, Optic radiation, Visual cortex (Lt. homonimous hemianopsia) involve 하는 massive hemispheric lesion의 가능성.

Formulation 82세 여자환자 : old age 의 CVA risk factor sudden onset neurologic deficit vascular origin임을 시사. SMA occlusion 의 cardioembolic problem 있음 sudden and maximal symptom onset  cardioembolism 가능성이 있음을 시사.

Impression #R/O Stroke Rt. Cerebral infaction Cardioembolism

Diagnostic Plan Brain DWI 

Brain CTA (2007.4.17) Rt. MCA M2 occlusion [Status] 정식판독입니다. [Reading Day] 2007/04/18 [Radiologist] ; 안은정/손철호 [Study Name] C/T: Brain Angio [Study Day] 2007/04/17 [Diagnosis] No significant interval change of CT finding taken on 2006-12-8. 1. No evidence of abnormal high or low density lesion. 2. Senile brain atrophy. --- R/O Subdural hygroma. --- Clinical correlation is recommended. 3. CTA : Calcific atherosclerosis in both cavernous ICA. [Finding] [Recommend] Rt. MCA M2 occlusion

Brain DWI (2007.4.17) Acute Rt. MCA infarction

Brain DWI (2007.4.18) Acute Rt. MCA infarction

Diagnosis Rt. MCA infarction

Treatment Therapeutic 1. antiplatelet agent 2. Bed rest and Conservative manage