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Case Presentation

Case Presentation. Son Eui Young 2007313075 Sungkyunkwan University School of Medicine. Chief Complaint. F / 56 Dizziness Onset : 1 days ago. Present Illness. 어제 저녁부터 시작된 어지럼증을 주소로 내원하였다 . 오늘 아침에 일어나니 더 심해졌다 . 누워있거나 일어나거나 전부 어지럽다 . Associated Symptoms Nausea/Vomiting

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Case Presentation

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  1. Case Presentation Son Eui Young 2007313075 Sungkyunkwan University School of Medicine

  2. Chief Complaint • F / 56 • Dizziness • Onset : 1 days ago

  3. Present Illness • 어제 저녁부터 시작된 어지럼증을 주소로 내원하였다. 오늘 아침에 일어나니 더 심해졌다. • 누워있거나 일어나거나 전부 어지럽다. • Associated Symptoms • Nausea/Vomiting • 이전에는 어지럼증이 한번도 없었다.

  4. Personal History • Past medical history • Hypertension/DM/TB/hepatitis/Allergy(-/-/-/-/-) • 2 weeks ago URI History (+) • Medication • No • Family history • Hypertension/DM/TB/hepatitis/Cancer(-/-/-/-/-) • Social history • Occupation: 주부 • Smoking: No • Alcohol: No

  5. Review of System • General Weakness(-) • Fatigue/ Weight change(-/-) • Fever/Chill/Night sweat(-/-/-) • Headache/Dizziness(-/+) • Visual disturbance/occular pain(-/-) • Sore throat/Rhinorrhea/Sneezing(-/-/-) • Cough/Sputum (-/-/-) • Dyspnea/Hemoptysis (-/-) • Chest pain (-) • Palpitation (-) • Abdominal pain (-) • Anorexia/Nausea/Vomiting(-/+/+) • Constipation/Diarrhea(-/-) • Melena/hematochezia/ hematemesis (-/-/-) • Dysuria/Frequent voiding(-/-) • Red urine/Foamy urine(-/-) • Arthralgia/Myalgia (-/-) • Morning stiffness(-/-/-) • Easily bruisilibility (-)

  6. Physical Examination • Vital sign • BP 116/74, HR 70, RR 20, BT 36.5℃ • General appearance: Not so ill-looking • Mental state: alert & well oriented • Head and Neck • Pinkish Conjunctiva/ unicteric Sclera • Isocoric Pupil size, prompt light reflex at both eyes • Nystagmus (+, Rt) • Otoscopy (정상) • oral ulcer ( - ), tongue dehydration ( - ) • Tonsilar hypertrophy( - ), Pharyngeal injection( - ) • Cervical LNE( -); • Thyroid enlargement ( - ) • Carotid bruit Rt/Lt ( - / - ) • Paranasal tenderness ( - ) • Chest • Symmetric expansion, Vesicular Breath sound s wheezing • Regular heart beat s murmur • Subclavicular node / Axillary node ( - / - ) • Skin • Rash/Purpura/erythema (- / - / - )

  7. Problem List • #1. Dizziness • #2. Nausea / Vomiting • #3. Nystagmus (+, Rt)

  8. Assessment • #1, 2, 3 : Vestibular neuritis Benign paroxysmal positional vertigo (no positional change) • #1 : Meniere disease(청력저하, 이명, 이충만감 없음) Stroke (다른 신경학적 이상 없음) Migraine Epilepsy • #1. Dizziness • #2. Nausea / Vomiting • #3. Nystagmus (+, Rt)

  9. Diagnostic Plan • Full Neurologic exam • 동반 될 수 있는 신경학적 징후를 확인 • Audiogram • 청력이상 확인 • Brain MRI • r/o Stroke

  10. Therapeutic Plan • For relieving symptoms • antiemetics, vestibular suppressant • Metoclopromide 10mg PO or IM tid • Dimenhydrinate 50mg /q 4-6 hours • Diazepam 2-10mg PO, IM or IV PRN, or 2mg PO bid • 48시간 이상 지나도 어지럼증이 전혀 호전되지 않거나 악화시 • CNS 문제 감별 위한 검사 필요(Imaging)

  11. Disease Review전정신경염 (Vestibular neuritis)

  12. Definition Vestibular labyrinth 3 semicircular canals 회전감 Otolith organs (utricle + saccule) 기울어짐

  13. Vestibular neuritis 원인 : 바이러스(m/c), 세균 등 난청 및 다른 신경학적 증상이나 징후 없이 갑자기 현훈, 안진, 오심, 구토가 발생한 후 수일에서 수주 내에 호전되는 경우 의심 30~40 대에 호발, 남녀 비율은 동일 병변의 반대쪽을 향하는 자발 안진이 관찰되고 병변쪽으로 쓰러지는 경향 상기도 감염이나 위장관염 등의 감염이 선행하기도

  14. Vestibular neuritis 대개 저절로 호전, 증상을 견딜 수 있으면 특별한 치료 無 심한 N/V, Dizziness가 있으면 증상 초기에 antiemetics, vestibular suppressant사용(최소량) Metoclopromide, Dimenhydrinate, Diazepam 심한 탈수  입원 후 포도당 주사 Steroid(?)  염증 완화, 빠른 회복 촉진

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