1. Case presentation
Int:雲智謙

2. P’t profile Name:許信裕 Gender：M Age：50 Chart No. :26243378
Date of admission:2010/08/22

3. Chief complaint
right facial numbness for half a year

4. Present illness
The 50 y/o male had hypertension with medical control. He complained of right facial numbness half a year ago initially, then the right tongue involved. He denied faical palsy, drooling, easily choking. He also had tinnitus then. He had double vision about one and half month ago, after the treatment in 阮綜合 hospital. The phenomenon of diplopia disappeared, but the numbness of right lower cheek and chin still persisted.

5. Present illness
He also complained of mild gait imbalance sometimes. He denied memory loss, headache, urinary incontinence. Because of above reason, he was arranged brain MRI and positive finding. Then he was admitted to our ward further management.

6. Past history DM: denied HTN: with medication control
Liver disease: denied
CVA
CAD
Asthma: denied
Other systemic disease: denied
Hospitalization history: denied

7. PE Consiousness: clear GCS: E4 V5 M6
Vital sign:BP: 124/73 mmHg, PR:81 bpm, RR:19 cpm,
BT:36.8 ℃
Sclera: not icteria, conjuctiva: not pail
Neck: Supple, Lymphadenopathy(-)
Chest: Inspection: symmetrical expansion
Auscultation: Bil. clear breathing sound, crackles(-) , regular heart sound, murmur(-)
Abdomen:
Extremities: pitting edema(-), ecchymosis(-),
freely movable

8. NE – high cortical function
JOMAC
Judgement: fair
Orientation: to 人 : fair
to 時 : fair
to 地 : fair
Speech: dysarthria(-)
Language: Fluency: ok, Repetition:ok, Comprehension:ok, Naming:ok

9. NE – cranial nerves I: smell: not test II: VA: ok VF: ok
II+III: light reflex R't / L't ( +/ + ) ( 3.0 mm/ 3.0 mm)
III+IV+VI: EOM is intact
0─┼x┼─ ─┼x┼─0
nystagmus: nil
diplopia: for ten days, about one and half ago
ptosis: nil
V: masseter: powerful
facial sensation: numbness at rigth V corneal reflex: R/L:(+/+)
V+VII: corneal reflex: fair

10. NE- cranial nerves VII: no facial palsy VIII: tinnitus
IX+X: uvula deviation: central position
gag reflex: fair
XI: trapezius: fair
SCM: fair
XII: tongue deviation: no deviation

11. NE – muscle tones and powers
Muscle tone: normal
Muscle power Right Left
Upper extremities
Lower extremities
Lhermitte sign(-), Hoffmann refelx(-/-) Babinski sign : plantar-flex/ plantar-flex Drop foot:(-)

12. NE - DTR DTR right left biceps ++ ++ triceps ++ ++ brachilis ++ ++
knee
achillis
Barbinski sign: dorsal- flex dorsal-flex

13. NE – sensory function pin-prick: bilateral lower limbs numbness
light touch: bilateral lower limbs numbness
vibration: bilateral lower limbs numbness
position sense: bilateral poor

14. NE – COORDINATION AND GAIT:
Coordination: FNF: no dysmetria HKS:no dysmetria tendem Gait: inbalanced, romberg test: normal
SENSORY FUNCTION pin-prick, light touch: 2+

15. Lab data

16. Available image MR

17. Different diagnosis
brain tumor, suspect meningioma
hydrocephalus