1. Case presentation
신경과 Pk15조
58번 이태영
76번 최병욱

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

3. Chief Complaint
Lt. sided weakness and dysarthria for 2 hours

4. 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.

5. 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 : 이상이라 복부비만.

6. 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

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

8. System Review
특이사항 없음.

9. 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  

10. 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

11. 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

12. 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

13. 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)

14. 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 (-/-)

15. 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

16. 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.

17. 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.

18. Impression
#R/O Stroke
Rt. Cerebral infaction
Cardioembolism

19. Diagnostic Plan
Brain DWI 

20. 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
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

21. Brain DWI ( )
Acute Rt. MCA infarction

22. Brain DWI ( )
Acute Rt. MCA infarction

23. Diagnosis
Rt. MCA infarction

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