Name : 전XX
Age : 74Sex : M
Occupation : 무직,
주거 : APT
General healthy : HTN/DM/Tb(+/-/-), hearing difficulty ; +/+
Medication : +
Alcohol : 소주1/2병/주1회, Smoking : 1갑/일#50년
Height : 173cm, Weight : 63kg
C.C. : 어지럽다.
Dx. : Cerebral infarction, Rt. MCA territory, Lt. PCA territory, both supraclinoid ICA mild stenosis
P.I : 3월5일, 21시경, 저녁먹은 후, 잠자리에 누울려고 하는데 dizziness 느꼈고, nausea, vomitting 1회 한 후,
dysarthria, ataxia(걸을 때 한쪽으로 쏠리는 느낌) 있었으나 집에서 경과관찰하다가 3월8일 LMC 방문해 시행한 MRI에서
Acute infarctions, in the both cerebelli, and right occipital lobe
Multiple posteiror circulation infarction (both PICA), Rt. PCA, Rt. SCA territory 로 본원 응급실 내원함.
PH> 15yrs ago, colon cancer OP
P/Ex.>
M/S : alert
Cooperation : Good
Cognition : intact
ROM : full
MMT : both u/e & l/e grossly Good
Functional level : ind. walking, tandem gait ; -, turn; +, squatting ; +, heel lift : +
Sensory> light touch, position both all intact
DTR> Rt. side all 2+, Lt. side B/J 1+, K/J 1+, A/J 1+
babinski (-/-), A. clonus(-/-)