1. Echocardiography Conference

2. History Taking C.C:Drowsy mentality, Rt side weakness (onset:내원 7시간전)
F/22,천O이
Adm via ER
1st adm
History Taking
C.C:Drowsy mentality, Rt side weakness
(onset:내원 7시간전)
Present illness:
F/22, 평소 건강히 지내던 자로서 내원 7시간전 갑자기 발생한 drowsy mentality, Rt side weakness를 주소로 위생병원 visit후 brain CT상 정상소견이나 further evaluation위해 본원 ER visit

3. History taking Past Medical Hx: DM/HTN/Hepatitis/pulm Tb:(-/-/-/-)
Op history:none
Drug medication Hx:none
bleeding tendency:none
Family History:Unremarkable
Personal History:
smoking:1 pack/day;7PY
Alcohol:none

4. Review of System
Incommunicable state

5. Physical examination V/S:110/70mmHg-110/min-36/min-36.9oC General:
drowsy mentality
Verbal response:+
Head & neck:
no neck v. engorgement
no thyroid gland enlargement
EENT&CN:
isocoric pupil with PLR(++)
Pinkish pupil with clear sclera
Intact EOM
Facial palsy: rt moderate

6. Physical examination Thorax: CBS without crackle
Rapid HB with diastolic murmur in lt apex, LLSB
Abdomen:
soft and flat abdomen
Normoactive BS
No abdominal T/RT
Back & Extremity:
No CVAT
Rt side hemiparesis: motor power Grade Ⅱ
DTR(+++/+++) Babinski & AC(+/-)
Rt side sense:0%

7. Initial lab findings ABGA:(O2 2L via NP):
mmHg-74.2mmHg-17.8mmol/L-94.9%
CBC/DC:
10,250mm3-13.6g/dL-39.9%-189k/mm3(seg:91.5%)
Chemistry:
TB/DB:0.8/0.2 mg/dL Protein/albumin:6.9/4.0g/dL
AST/ALT:28/14 U/L ALP/LD:47/417 U/L
BUN/Cr:9/0.7 mg/dL e’: mmol/L

8. Initial lab findings Cardiac markers: CK/CK-MB/TnI:110/3.4/0.02 ng/mL
Lipid profile(6.21.시행)
T-chol/TG:101/60mg/dL
LDL/HDL:57/34 mg/dL
PT/PTT:14.0sec(1.08%)/42sec
U/A:
RBC:5~9/HPF, WBC:0~1/HPF

9. EKG

10. Chest AP:내원 당일

11. Brain MRI

12. Brain MRI

13. Brain MRA

14. Echocardiography