박상호 선생님SOAP #3

] # Gait disturbance d/t cbl mass, both Cbll hemisphere, superior vermis, r/o Breast cancer metastasis # r/o impaired cognition # r/o dysarthria # r/o dysphagia # s/p hydrocephalus (2015.1.21. Ventriculo-peritoneal shunt (Codman Hakim programmable vavle pressure: 20CmH2O)) # Multiple intra axial mass on Rt tempral base, both Cbll hemisphere, superior vermis, r/o Breast cancer metastasis # Metastatic breast cancer (LN, Bone, Lung)   주호소 또는 입원사유 Drowsy mentality 경과 및 특이소견 # P / I Known breast ca pt로 2012.10.05 Lt breast core needle Bx. 상 invasive ductal carcinoma 진단 2012.10.31. PET CT: Left breast cancer with ipsilateral axillary LNs, bone and R/O lung metastases (cT2N1M1, stage 4 state) 2012.11.07 chest, abd CT: 1) Multiple small metastatic lymphadenopathies in the left axilla and mediastinum. 2) Mild interstitial thickening and small nodules in the right lower lobe. 2012.11.09 bone scan: Left 9th rib의 posterior arc에 minimal tracer uptake * Pathology : ER/PR/HER-2 (+ 5/+ 5/3+) 2012.11.06/11.13 Herceptine+ wP #1 (+zometa) 2012.12.04/12.11 Herceptine+ wP #2 (+zometa) 2012.12.25/01.03 Herceptine+ wP #3 (+zometa) 2013.01.17/01.24 Herceptine+ wP #4 (+zometa) 2013.02.06/02.13 Herceptine+ wP# 5 (+zometa) 2013.02.28/03.07 Herceptine+ wP# 6 (+zometa) 2013.03.21 chest/abd CT f/u 2013.03.21/03.29 Herceptine+ wP# 7 (+zometa) 2013.05.21 Herceptin #10 2013.06.10 Lt. MRM /c ALND IDC G2 ypT1N0M1 -> palliative RTx 2013.06.27 Herceptin #11 2013.07.18 Herceptin #12 2013.07.31 Headache w/u brain MRI : multiple cbll mass r/o meta, superior cbll vermis 14mm, right inferior cbll hemisphere 13mm, left cbll hemisphere 12mm 2013.08.06 brain RT 및 nolvadex + zometa 시행 2013.09.10 -2014.05.26 T-DM1 #13까지 시행함. 2014.06 Brain MRI : Rt temporal mass 2014.06.23 FEC#1 로 항암제 변경하여 1차 시행 2014.07.22 FEC#2 시행 후 퇴원함. 2014.08.19 FEC #3 시행 후 퇴원 2014.09.15 Brain MRI : mass size increasing 2014.11.20 Brain RTx 10회 시행함. 이후로도 headache 있어 입퇴원 반복하였던 환자로 두통 발생시마다 steroid Tx. 받으며 conservative Tx 받으며 경과관찰. 2015.01.20 headache agg. 및 drwosy mentality 보여 본원 응급실 방문, Brain CT : Whole ventricular system enlargement (Evans'ratio 0.32) 소견 보여 NS Adm. 2015.01.21 V-P shunt 시행. IV Abx (01/21~01/22 Meicelin 1g qd, 01/23~01/26 Meicelin 1g bid) 2015.01.26 GKRS 시행 : Methionine-PET 상 uptake 된 재발병변만 시행. GKRS MRI 이후 shunt pr 18mmH2O 로 reset 2015.01.29 Protective cough dev. 2015.01.31 Protective cough agg. 하여 L-tube feeding start. 2015.02.02 포괄적 재활치료 위해 재활의학과 전과함. # Personal History alcohol : 주 1~2회, 맥주 반병 smoking : none occupation : 바이올린 강사 # Family History 아버지, 폐암. # Past History HTN/DM/Tbc(-/-/-) Op Hx : (+) Appendectomy C-sec # General Physical Exam G/A : chronic ill looking face : not puffy eye - not pale, anicteric mouth – not dried neck : NVD(-/-) chest : symmetric /s deformity heart - regular /s murmur lung – clear /s rale abdomen : soft & flat extremity : N-S # Neurologic Exam mental status : alert cooperation : good memory : ST/LT(+/+) orientation : time/place/person(+/+/+) speech : dysarthria fluency/comprehension/repetition/naming (+/+/+/+) neglect(-), apraxia(-), disinhibition(-), abulia(-), anosognosia(-) mutism(-), depression(-), aphasia(-) Cranial nerve exam pupil : size : 3mm/3mm light reflex(+/+) diplopia(-) nystagmus(-) face : forehead wrinkling(+/+) eye close(+/+) ciliary sign(+/+) mouth angle deviation(-) nasolabial fold flattening(-) mouth : gag reflex(+/+) uvular deviation(-) tongue deviation(-) fasciculation(-) shrugging(+/+) SCM muscle(+/+) Cerebellar function test F to N to F(imp/imp) heel to shin(imp/imp) diadochokinesia(imp/imp) truncal ataxia(+) tremor(-) Romberg test(NT) MMT Rt/Lt Rt/Lt Shoulder/Flexor (G/G) Hip/Flexor (G/G) Elbow/Flexor (G/G) Knee/Extensor (G/G) Wrist/Extensor (G/G) Ankle/Dorsiflexor (G/G) Elbow/Extensor (G/G) Long Toe/Extensor (G/G) Finger/Flexor (G/G) Ankle/Plantarflexor (G/G) Finger/Abductor (G/G) Hip/Extensor (G/G) Hip/Abductor (G/G) MSR Rt / Lt biceps jerk (++/++) knee jerk (++/++) ankle jerk (++/++) Babinski reflex (-/-) Hoffmann sign (-/-) ankle clonus (-/-) ROM : full ROM Shoulder subluxation : (-/-), Pain/Td(-/-) upper lower Sensory : pain/temp (N/N) (N/N) light touch (N/N) (N/N) posi/vibration (N/N) (N/N) Neuropathic pain : (-) Motor control : BBS: Motricity index A:100 L:100 T:48 Brunnstorm stage A:6 H:6 L:6 Muscle tone : not increased Spasticity : MAS upper (G0/G0) lower (G0/G0) Bladder : self, 3~4/d, 1~2/n, filling/passage (+/+), voiding difficulty(-) Bowel : 1/1d, consistency: soft, incontinence(-) Feeding : L-tube, protective cough(+), aspiration pneumonia(-) # Functional Exam supine to side-lying : (+) /c min assist supine to sitting : (+) /c mod assist sitting without support : (+) /c min assist dynamic sitting balance : (+) /c mod assist both legs standing : (+) /c min assist one leg standing : (+) /c max assist walking : (+) /c mod assist # Gait pattern foot drop (-) genu recurvatum (-) circumduction (-) # ADL feeding/grooming/dressing: dependent /c mod support bathing/toileting: dependent /c mod support