อาการวิทยา
(SYMPTOMATOLOGY)
Case Study: Part 2
Introduction to Clinical Medicine
วิชาบทนําเวชศาสตร์คลินิก (RAID 303) นักศึกษาแพทย์ชั้นปีที่ 3
คณะแพทยศาสตร์โรงพยาบาลรามาธิบดี มหาวิทยาลัยมหิดล
PART 2
Headache A 30-year-old house-wife presents with paroxysmal unilateral throbbing headache at right temporal area for 4 years. The headache lasts 1-2 hours and is sometimes accompanied with nausea and vomiting and also occurs occasionally on the left side. She has no other symptoms. She takes birth control pills for 2 years.
General examination Vital signs T 37oC, PR 80/min, RR 18/min, BP 130/80 mmHg General A middle-aged female, not pale, appearance no jaundice HEENT normal CVS normal Lungs clear Abdomen normal No cervical or cranial bruit
2 | Symptomatology part 2
PART 2 Neurological examination Alert, normal speech, normal gait, no stiffness of neck Cranial nerves Normal fundi Pupils 3 mm in diameter with good reaction to light Full EOM Normal visual field No facial palsy Normal hearing Motor system Normal tone and no weakness Normal deep tendon reflexes No Babinski’s sign Cerebellar sign Normal Sensory Intact to all modalities system
Question 1. What is the main problem of this patient? 2. Analyse the information from history and physical examination, and give your differential diagnoses.
Symptomatology part 2 | 3
PART 2 Case Study
Unconsciousness The 65-year-old man was sent to the emergency room by his son because he was found unconsciousness for 1 hour. He complaint of headache and dizziness for about 1.5 hours and told his son that he would like to go to sleep. He was also vomiting once. After he slept for 1 hour, his son tried to wake him up but he did not have any response. He also passed urine on the bed. His son immediately sent him to the hospital. The patient has the underlying diseases of diabetes mellitus and hypertension for 5 years. He has a poor c ompliance of medical treatment. He smokes cigarette 1 pack/day and drinks beer 3 bottles/day for more than 10 years. Physical examinations Vital signs T 37oC, PR 58/min, RR 14/min, BP 220/120 mmHg General An old man, unconsciousness, not pale, appearance no jaundice, can breath spontaneously HEENT unremarkable CVS JVP normal Apex at 2 inches lateral to mid clavicular line, heaving, no thrill, normal S1, S2, no murmur
4 | Symptomatology part 2
PART 2 Physical examinations RS apneustic breathing, normal breath sound Abdomen unremarkable Nervous Coma, Glassgow coma score E1 M2 V1 system CN Fundi normal disc, A:V 1:4, exudates and multiple small hemorrhages were seen EOM no conjugate eye deviation, Doll’s eye present Pupils 2 mm in diameter, react to light poorly Motor decerebrate to pain stimuli Sensory cannot be evaluated Deep tendon reflexes 3+ all Bilateral Babinski sign No neck stiffness
Question 1. What is the main problem of this patient? 2. Analyse the information from history and physical examination, and give your differential diagnoses.
Symptomatology part 2 | 5