case presentation int: 雲智謙 99.08.25. p’t profile name: 許信裕 gender ： m age ： 50...

Case presentation

Int: 雲智謙99.08.25

P’t profile

• Name: 許信裕• Gender ： M

• Age ： 50

• Chart No. :26243378

• Date of admission:2010/08/22

Chief complaint

• right facial numbness for half a year

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.

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.

Past history

• DM: denied

• HTN: with medication control

• Liver disease: denied

• CVA

• CAD

• Asthma: denied

• Other systemic disease: denied

• Hospitalization history: denied

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

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

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 0 0 0

• 0─┼x┼─0 0─┼x┼─0

• 0 0 0 0

• nystagmus: nil

• diplopia: for ten days, about one and half ago

• ptosis: nil

• V: masseter: powerful

• facial sensation: numbness at rigth V3 corneal reflex: R/L:(+/+)

• V+VII: corneal reflex: fair

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

NE – muscle tones and powers

• Muscle tone: normal • • Muscle power Right Left

Upper extremities 5 5

Lower extremities 5 5

Lhermitte sign(-), Hoffmann refelx(-/-) Babinski sign : plantar-flex/ plantar-flex Drop foot:(-)

NE - DTR

• DTR right left

• biceps ++ ++

• triceps ++ ++

• brachilis ++ ++

• knee +++ +++

• achillis +++ +++

• Barbinski sign: dorsal- flex dorsal-flex

NE – sensory function

• pin-prick: bilateral lower limbs numbness

• light touch: bilateral lower limbs numbness

• vibration: bilateral lower limbs numbness

• position sense: bilateral poor

NE – COORDINATION AND GAIT:

• Coordination: FNF: no dysmetria HKS:no dysmetria tendem Gait: inbalanced, romberg test: normal

• SENSORY FUNCTION pin-prick, light touch: 2+

Lab data

Available image

• MR

Different diagnosis

• brain tumor, suspect meningioma

• hydrocephalus