Transcript 20060612_infarction_..

Case discussion.
Vs 李宜中,R1林玫瑩
General data:
Name: 賴錦x
 Age:52 years old
 Occupation:鐵工廠老闆
 Admission date:2006/5/30.

C.C:

Sudden onset of slurred speech,
numbness and weakness over left limbs
in the evening of 95/5/29.
Present illness:

Hypertension with medical control for half
year.
 95/5/17: intermittent left hand numbness and
dizziness -署立苗栗醫院 - left hemiparesis,suspect TIA-5/17:brain CT: brain atrophy
without significant abnormality.-S/P hydrationsymptom improved-discharged on 5/22.
 After discharge :intermittent dizziness + left
hand numbness.
95/5/29: sudden onset of dizziness +left
hand numbness +left limb weakness
several minutes -署立苗栗醫院. Brain
CT:no significant abnormality.
 Conscious drowsiness –transferred to
our ER: NE: Left hemiparesis,
conscious drowsiness, poor response to
deep pain over left limbs and left
homonymous hemianopia.

Past history:HTN with medical control
for half year.
 History of TIA in 5/17.
 Smoking:1PPD for 35 years, not quit.
 Alcohol consumption:social drinking for
35 years.

NE:
Conscious:clear, orientated, memory:
normal, abstract thinking:normal,
attention: normal.
 Mild dysarthria.
 Crainal nerve :light reflex:+/+,left side
hononynous hemianopia.Corneal
reflex:+/-.left side central type facial
palsy.tongue deviated to the left.

Motor exam:muscle tone: hypotonia
over left limbs.muscle strength:right
U/L:5/5,left U/L:0/0.
 Sensory exam: impaired pinprink test
over left V2+V3, left limbs.Joint position:
impaired over left limbs.
 Reflex: right U/L:++/+, left lower
U/L:++/+.Barbinski sign: both
plantarflexion.
 Cerebellar sign:right side : FNF, RAM
and HKS.left side can’t evaluate.

PE:
HEENT: no pale conjunctiva.
 Neck: no LAP.
 Chest: clear breathing sound.
 Heart : RHB.
 Extremity: no pitting edema.
 No body weight loss.

Impression:
Acute cerebral infarction ,suspect right
MCA territory.
 Hypertension.

Hospitalization.
N/S hydration +tapal+Gina.
 Due to young onset: 6/6:MRA
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MRI:
Conclusion:
1. Occlusion or thrombotic right ICA under
collateral circulation came from fine
stenotic ACoA and right PCoA forright
MCA territory with insufficiency and
infarction under gyral pattern petechiae
and enhancement with mass effect.
2. Multiple separated enhanced nodules
in right side cerebral sulci and beneath
right temporal horn. R/O multiple
seeding tumor or metastasis,
significance?

CXR: No active lung lesion.
 Abdomen sonography:Mild fatty liver
and coarse echoes.Small GB with polyp.
 No body weight loss.No LAP.

Final diagnosis:
Acute cerebral infarction, right F-T-P
region due to right side ICA occlusion.
 Suspect multiple tumor seeding or
tumor metastasis.
