1. Drowsy mentality와 Rt. side weakness를 주소로 내원한 22세 여자환자

2. C.C : Drowsy mentality, Rt side weakness (onset:내원 7시간전)
F/22,천O이
Adm via ER
1st adm
C.C : Drowsy mentality, Rt side weakness
(onset:내원 7시간전)
Present Illness:
평소 건강히 지내던 자로서 내원 7시간 전 갑자기 발생한 drowsy mentality, Rt. side weakness를 주소로 위생병원 방문 후 brain CT상 정상소견이었으나 further evaluation위해 본원 ER visit

3. Past Medical Hx.:
DM/HTN/Hepatitis/pul. Tb:(-/-/-/-)
Op. history:none
Drug medication Hx.:none
bleeding tendency:none
Family History:Unremarkable
Personal History:
smoking : 7 P.Y for 7yr.
Alcohol : none

4. Review of System
Incommunicable state

5. Physical examination V/S:110/70mmHg-110/min-36/min-36.9oC General:
drowsy mentality
Verbal response (+)
Head & neck:
no neck v. engorgement
no palpable mass
E/ENT&CN:
isocoric pupil with PLR(++/++)
Pinkish conjunctiva with clear sclera
Intact EOM
Facial palsy : Rt. moderate

6. Physical examination Thorax: CBS without crackle
Rapid HB with diastolic murmur at apex & LLSB
Abdomen:
soft and flat abdomen
Normoactive BS
No abdominal T/RT
Back & Extremities:
No CVA tenderness
Rt. side hemiparesis : motor power Grade Ⅱ
DTR (+++/+++) Babinski (+/-)

7. Impressions #1.Stroke embolic/thrombotic cardiogenic (VHD) hemorrhagic
지금까지의 소견을 종합하여 stroke과 pulmonary congestion을 imp.으로 생각되었습니다.stroke 은 brian CT 상 정상소견이었기 때문에 hemorrhagic보다는 emboilitic/thrombotic stroke을 의심하였습니다.
Pulmonary confestion 에 대한 원인으로 ㅊ

8. Diagnostic plans
#1. Stroke
1. Brain MRI & MRA
2. Echocardiography

9. Initial lab findings ABGA:(O2 2L via NP):
mmHg-74.2mmHg-17.8mmol/L-94.9%
CBC/DC:
10,250mm g/dL-39.9%-189k/mm3 (seg:91.5%)
Chemistry:
TB/DB:0.8/0.2 mg/dL Protein/albumin:6.9/4.0 g/dL
AST/ALT:28/14 U/L ALP/LD:47/417 U/L
BUN/Cr:9/0.7 mg/dL e’: mmol/L

10. Initial lab findings Cardiac markers: CK/CK-MB/TnI:110/3.4/0.02 ng/mL
Lipid profile:
T-chol/TG:101/60mg/dL
LDL/HDL:57/34 mg/dL
PT/PTT :14.0sec(1.08%)/42sec
U/A : RBC:5~9/HPF, WBC:0~1/HPF

11. EKG

12. Chest AP

13. Brain MRI

14. Brain MRI( )

15. Brain MRA( )

16. TTE( )

17. TEE

18. Heart SPECT

19. Summary Brain MRI : Lt BG,PVWM new infarct
Brain MRA : Lt.MCA occlusion
Echo :
Severe MS
LA enlarged (5.0cm*4.5cm)
No evidence of LA thrombi
Hypo to akinesia of apical septum
and ant.wall

20. Summary TEE: Severe MS with rheumatic origin
Spontaneous Echo Contrast in LA
No definite thrombus or sludge
Heart SPECT:
No significant perfusion abnormality

21. Diagnosis
Lt. Basal ganglia, PVWM infarction with Mitral stenosis

22. 2. Mitral valve replacement
Treatments
1. Anticoagulation
2. Mitral valve replacement