1 / 32

심 O 헌 (M/42)

심 O 헌 (M/42). 성균관대학교 의과대학 2007313075 손의영. Chief complaint (11.7.10). Headache Onset (about) 1WA. Present Illness (1). 2011-09-15 ( 내원 3 일 전 ) 정확하게 언제인지는 모르나 어느 순간 부터 심한 머리 통증 발생 Nausea, vomiting 동반되었으며 통증은 순식간에 심해진 것 같다고 함 Headache Location 우측 귀 뒤쪽  이후 머리 전체로 퍼짐

calvinu
Download Presentation

심 O 헌 (M/42)

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. 심O헌 (M/42) 성균관대학교 의과대학 2007313075 손의영

  2. Chief complaint (11.7.10) • Headache • Onset(about) 1WA

  3. Present Illness (1) • 2011-09-15 (내원 3일 전) • 정확하게 언제인지는 모르나 어느 순간 부터 심한 머리 통증 발생 • Nausea, vomiting 동반되었으며 통증은 순식간에 심해진 것 같다고 함 • Headache • Location우측 귀 뒤쪽  이후 머리 전체로 퍼짐 • Nature머리 전반이 짓누르는 듯한 양상가끔 박동 뛰듯이 아픔

  4. Present Illness (2) • Headache • Severity 10/10 • Associated Sx N/V (+/+) photophobia/phonophobia (–/–) autonomic Sx (–) febrile sensation/chill/myalgia (–/–/–) URI Sx (–) trauma (–) • 2011-09-18 • 상기 두통 증상 지속되어 내원함

  5. Past medical history • HTN / DM/ TB / hepatitis / allergy (+/-/-/-/-) • 2007-09-26 • SMV, portal vein thrombosis, small bowel gangrene •  SMC : thrombectomy c Fogarty catheter, small bowel resection & anastomosis • 2008-05 • Anticoagulation 시작

  6. Past medical history • 2009-08 • 간헐적인 Rt. Sided weakness 및 dysarthria 발생 • Local MRI에서는 정상 • 2011-08 (1MA) • Chest pain 및 general weakness로 local 동인요양병원 입원 Isosorbide mononitrate 복용 시작 • 갑자기 말발음이 더 어둔해지면서 입이 돌아감 (방향은 모름, general weakness 동반) • 당시 머리가 아프지는 않았으며, 약간의 nausea(+) • 1~2일만에 증상 호전되어 말발음도 이전과 비슷함.

  7. Warfarin • 이소빈서방캅셀 50mg (Isosorbide mononitrate) • 흉통 있을 때 간헐적으로 복용 • Zolpidem • Amlodipine • Metoclopramide 4mg tid Medication history

  8. Family Hx • 특이사항 없음 • Social Hx • Smoking no (약 3년 전 quit) • Alcohol no Other Histories

  9. Review of system • General weakness/fatigue (+/-) • Weight loss (-) • Fever/chill (-/-) • Visual disturbance/ocular pain/discharge (-/-/-) • Sore throat/rhinorrhea/sneezing (-/-/-) • Cough/sputum/hemotpysis (-/-/-) • Dyspnea/orthopnea (-/-) • Chest pain/ palpitation (-/-) • Anorexia/nausea/vomiting (-/-/-) • Abdominal discomfort/pain (-/-) • Constipation/diarrhea (-/-) • Hematemesis/melena/hematochezia (-/-/-) • Dysuria/oliguria/frequent voiding (-/-/-) • Foamy urine/red urine (-/-) • Arthralgia (-) • Myalgia (-) • Tingling sense (-) • Morning stiffness (-)

  10. Physical examination • Vital sign • 135/88 mmHg – 65 /min – 20 /min – 36℃ • General appearance • Chronic ill-looking appearance • Head & neck • Conjunctiva pinkish • Sclera clear • Pupil size symmetric, no myosis on both pupil • Light reflex prompt response on both pupil • Tongue not dehydrated • Tonsilar enlargement no • Gingival hypertrophy no • Gum bleeding no • Palpable neck mass no • Chest • Symmetric expansion • Regular heart beat without murmur • Supraclavicular node (-/-) • Axillary node (-/-) • Percussion resonance, symmetric • Vesicular breath sound without crackle, wheezing, rhonchi • Abdomen • Flat abdomen, soft on palpation • Normoactive bowel sound • Hepatomegaly/splenomegaly/shifting dullness (-/-/-) • Pain/tenderness/rebound tenderness (-/-/-) • Palpable abdominal mass (-/-)

  11. Neurologic examination (1) • Mental status examination • Level of consciousness alert • Orientation Time/Place/Person (+/+/+) • Language fluent with well comprehension

  12. Neurologic examination (2) • Cranial nerve examination • Visual acuity normal (no glasses) • Visual field defect (-) • EOM full • Pupil Isocoric • Light reflex (＋＋/ ＋＋) • Nystagmus None • Mastication Symmetrically intact • Facial motor Symmetrically intact • Facial sensory Symmetrically intact • Uvular/Tongue deviation (-) • SCM & trapezius muscle Symmetrically intact

  13. Motor examination : muscle power • Upper extremities IV/V • Lower extremities IV/V • Motor examination : muscle contour • No atrophy • Sensory examination • Touch 오른쪽에 mild hypesthesia • Pain 오른쪽에 mild hypesthesia • Position symmetrically intact Neurologic examination (3)

  14. DTR • Brachioradialis (++/++) • Biceps (++/++) • Triceps (++/++) • Quadriceps (+/+) • Ankle (+/+) • Plantar extensor reflexes Babinski (-/-) Chaddock (-/-) Neurologic examination (4)

  15. Coordination and gait • Cerebellar function test • Rapid alternating movement dysdiadochokinesia (-/-) • Finger-to-nose intentional tremor (-/-) • Heel-to-shin dysmetria (-/-) Neurologic examination (5)

  16. Coordination and gait • Gait • Step mild Rt. Leg limping • Romberg test (-) Neurologic examination (6)

  17. Problem List (1) • #1. Headache • Severe, continuous • With nausea, vomiting • #2. Chronic neurologic deficit • Rt. arm/leg weakness with hypesthesia

  18. Problem List (2) • #3. Hypertension • #4. Angina pectoris • #5. SMV, Portal vein thrombosis, small bowel gangrene •  embolectomy, small bowel resection

  19. Assessment #1. r/o secondary headache • Etiology : r/o Cerebral venous thrombosis r/o Sub-dural hematoma r/o aneurysm r/o pituitary apoplexy #2. r/o Chronic ischemic stroke r/o venous infaraction, mainly Lt. hemisphere - sequele: Rt.sided weakness (arm, leg GIV) Rt.sided hypesthesia (face,arm,leg) dysarthria mild word finding difficulty

  20. Assessment #3. Hypertension #4. Angina pectoris #5. SMV, Portal vein thrombosis, small bowel gangrene

  21. Diagnosticplan • Brain MRI, MR venography • 병변 부위 확인 • Funduscopy, visual field check • ICP 증가 여부 확인

  22. Brain CT (2011-09-18) CONCLUSION: Suggestive of dural sinus thrombosis involving right transverse sigmoid sinus and internal jugular vein.

  23. T1 MRI

  24. T2 MRI (sagittal view)

  25. MR venography

  26. Funduscopy

  27. #1. r/o cerebral venous thrombosis • Location: superior sagittal  Rt. Transverse sinus • Etiology: hypercoagulability (protein C/S def, AT-3 def…) vasculitis • #2. Chronic ischemic stroke • Localization : Lt. corona radiata, post. Limb of internal capsule, pons • Etiology: r/o embolism Reassessment

  28. For CVT • Heparin + Warfarin • For IICP • Mannitol, glycerin • 1주 경과 관찰 후 두통호전 확실치 않거나 시력 저하등을 호소할 경우 thrombolysis 고려 Therapeutic plan

  29. Cerebral venous thrombosis • 역학 • 젊은 여성 > 남성 • 전체 환자의 약 6∼12%는 감염과 관련있다. • 원인과 위험인자 • 혈전 호발상태, 감염, 염증병, 혈액조건, 약물, 기계적 원인 • Idiopathic

  30. Cerebral venous thrombosis • Pathophysiology • Cortical vein 막힘  뇌의 허혈 변화, 출혈, 뇌부종 동반가능 • Dural venous sinus 막힘  이 부근 정맥압 증가  arachnoid villi를 통해 CSF가 흡수되지 않으므로 두개내압이 상승한다.

  31. Cerebral venous thrombosis • Clinical manifestation • 뇌정맥 혈전은 동시에 여러 뇌정맥을 침범할 수 있기 때문에 특징적인 증상이 없고, 다양한 증상이 나타난다. • 두통(75%) : 대부분 수일에 걸쳐 지속적으로 심해짐 • 경련(40%) : 이 중 12~15%는 첫 증상으로 발현되기도 함 • 의식저하(30%) : 비교적 나중에 발현 • 혈전이 발생한 cortical vein의 영역에 따라 팔다리의 운동 및 감각장애, 실어증, 뇌신경마비 등이 발생 가능 • ICP 상승 : funduscopy에서 papilledema 가 발견됨

  32. Cerebral venous thrombosis • Diagnosis • Cerebral angiography • Imaging (CT, MRI…) • D-dimer는 도움 안됨 • Treatment • anticoagulation : to suppress blood clot formation • thrombolysis : 효과가 확실히 증명 된 것은 아님 • ICP가 증가된 경우 lumbar puncture나 medication으로 압력을 낮춰주면 증상의 호전을 기대할 수 있다.

More Related