1. Missed case 2006.7.7 EM R2 김현진

2. 김 0 순 F/65 (5100921) C.C : headache C.C : headache D: 내원 3 일전 (6/23 23 시 ) D: 내원 3 일전 (6/23 23 시 ) P/Hx. P/Hx. HTN/DM/Tbc/hepatitis(+/-/-/-) HTN/DM/Tbc/hepatitis(+/-/-/-) HTN : 10 년 전부터 med. HTN : 10 년 전부터 med. P.I. P.I. 65 세 여자환자로 내원 3 일전부터 발생한 두통과 왼손바닥 저림을 주소로 내원함. 65 세 여자환자로 내원 3 일전부터 발생한 두통과 왼손바닥 저림을 주소로 내원함.

3. Headache profile Onset : 내원 3 일전 (6/23 23 시 ) Onset : 내원 3 일전 (6/23 23 시 ) Duration : intermittent Duration : intermittent Character : 오른쪽 뒷머리부터 앞쪽으로 지끈거리며 아 프다 Character : 오른쪽 뒷머리부터 앞쪽으로 지끈거리며 아 프다 Nausea/vomiting (-/-) Nausea/vomiting (-/-) Aura (-) Aura (-) Risk factor : hypertension Risk factor : hypertension Aggrevation factor : none Aggrevation factor : none Releif factor : none Releif factor : none Association sx : 왼손바닥이 저리다 Association sx : 왼손바닥이 저리다

4. R.O.S Fever/chill(-/-) Fever/chill(-/-) Headache/dizziness(+/-) Headache/dizziness(+/-) Cough/sputum(-/-) Cough/sputum(-/-) Nausea/vomiting(-/-) Nausea/vomiting(-/-) Chest pain/dyspnea (-/-) Chest pain/dyspnea (-/-) Abdominal pain/diarrhea/constipation (-/-/-) Abdominal pain/diarrhea/constipation (-/-/-) Hematemesis/hematochezia(-/-) Hematemesis/hematochezia(-/-) Dysarthria(-) Dysarthria(-) Lt palm paresthesia(+) Lt palm paresthesia(+)

5. P/Ex G/A : Not so ill-looking appearance G/A : Not so ill-looking appearance HEENT : Isocoric pupil (4/4mm) c PLR HEENT : Isocoric pupil (4/4mm) c PLR Not icteric sclerae Not icteric sclerae Not pale conjuctivae Not pale conjuctivae Chest : Clear B/S without rale Chest : Clear B/S without rale Regular H/B without murmur Regular H/B without murmur Abdomen : Soft &flat Abdomen : Soft &flat NABS NABS No direct/rebound tenderness No direct/rebound tenderness Back and Extremity : Back and Extremity : No CVA tenderness No CVA tenderness No pretibial pitting edema No pretibial pitting edema

6. N/Ex Alert mental status Alert mental status Cbr Fx: orientation: T/P/P(+/+/+) comprehension/attention: intact language: intact Cbr Fx: orientation: T/P/P(+/+/+) comprehension/attention: intact language: intact CNFx: isocoria PLR(+/+) CNFx: isocoria PLR(+/+) no facial palsy no facial palsy no diplopia no diplopia Motor: GV/GV Motor: GV/GV GV/GV GV/GV Sensory: light touch/position : intact Sensory: light touch/position : intact CBllFx : FTN/RAM/HTS/Romberg/Tandem : intact CBllFx : FTN/RAM/HTS/Romberg/Tandem : intact

7. Impression Migraine Migraine R/O Intracranial hemorrhage R/O Intracranial hemorrhage

8. Plan Routine lab (CBC, electrolyte..) Routine lab (CBC, electrolyte..) Brain CT with contrast Brain CT with contrast Pain control Pain control

10. Progress 6/23 23 시 증상발생 6/23 23 시 증상발생 6/26 06 시 ER 내원 6/26 06 시 ER 내원 6/26 07 시 20 분 Brain CT 촬영 6/26 07 시 20 분 Brain CT 촬영 6/26 08 시 증상 호전되어 당일 14 시 신경과 김경환선생님 외래 예약하고 퇴원 6/26 08 시 증상 호전되어 당일 14 시 신경과 김경환선생님 외래 예약하고 퇴원

11. Progress 6/26 14 시 신경과 김경환선생님 외래 방문 6/26 14 시 신경과 김경환선생님 외래 방문 6/26 14 시 25 분 입원 위해 ER 로 refer 됨 6/26 14 시 25 분 입원 위해 ER 로 refer 됨

12. 재내원시 NEx Alert mental atstus Alert mental atstus CbrFx : orientation: T/P/P(+/+/+) CbrFx : orientation: T/P/P(+/+/+) comprehension/attention: intact comprehension/attention: intact language/memory: intact/recall 2/3 language/memory: intact/recall 2/3 calculation: 간단한 계산은 가능 calculation: 간단한 계산은 가능 CNFx : isocoria PLR(+/+) CNFx : isocoria PLR(+/+) no facial palsy no facial palsy Lt. hemianopia Lt. hemianopia no tongue/uvular deviation no tongue/uvular deviation Motor : Upper prox. GV/GV dist. GV/GV Motor : Upper prox. GV/GV dist. GV/GV no pronator drift no pronator drift Lower porx. GV/GV dist. GV/GV Lower porx. GV/GV dist. GV/GV Sensory : light touch/pinprick/position/vibration: intact Sensory : light touch/pinprick/position/vibration: intact CbllFx : FTN/RAM/HTS: intact CbllFx : FTN/RAM/HTS: intact Romberg/Tandem: intact Romberg/Tandem: intact DTR : normoactive, symmetric DTR : normoactive, symmetric Babinski / AC : (-/-) Babinski / AC : (-/-)

13. Final diagnosis Rt PCA infarction Rt PCA infarction

14. Progress cerebral angiography(6/30) cerebral angiography(6/30) Total occlusion of right M1 segment is seen on right ICA angiogram. Right P1 occlusion is also noted. Total occlusion of right M1 segment is seen on right ICA angiogram. Right P1 occlusion is also noted.