PC;

55y/o Chinese lady presented with

HOPI:

Previously well, history by family members, on 27/11/18, patient was in a meeting in

an office at 8.30pm when colleagues noticed patient was slanting to one side and
was not talking. ?loss of consciousness. According to patient, she was unable to
remember/recall what happened to her during the meeting. Her brother was notified
by the colleagues by 9pm and an ambulance brought to ED in UMMC by 10.45pm.

No previous chest pain/SOB/failure symptoms/IHD, non-smoker, non-drinker, no

blood thinners/OCPs, no headache, no vision changes, no nausea/vomiting, no
fever, no difficulty in swallowing,
PU/BO normal

CT brain done at 11.17pm which showed no acute infarct.

CTA brain: left M1/M2 stenosis
Stroke protocol activated at 12.05am, NIHSS 20
Thrombolysis given after discussion with specialist – 12.40am and agreed by family
members.

History of similar complaints in June 2018 – generalised lethargy, blurry vision,

unable to speak and hear which resolved in 30 mins. – when asked > pt said this
was the first time.

PM/SHx;
1. Bilateral glaucoma - under clinic follow up in Penang
- on medication - eyedrops?
No previous surgery.

Drug/allergy;
- eye drops
- allergic to NSAIDS/ponstan/ibuprofen - develops periorbital oedema

Family/Social;
Mother - heart problems
father passed away
6 siblings - all well
married with one son. Husband is a pastor who works under a church organisation –
frequently travels to Sibu and Penang. Son is studying in Nottingham Uni. In
Semenyih. Patient is a kindergarden teacher also under church organisation in
Penang, was in KL for a meeting. Husband will be main carer for the patient.
Expectation is to return back to work and pre-morbid health.
PE: on admission
Alert, GCS E3V1M5, obeys command, UL/LL no drift, lungs clear
Vitals: BP 110/49, HR 81, T 36.8
Global aphasia
Able to name objects, able to obey 3-step commands, mild receptive and expressive
dysphasia (appears slow).
Able to read, difficult to write in sentences.
Peripheral visual field normal.
Mild facial asymmetry

B/L UL 4/5
B/L LL 4/5
No sensory deficit, no pronator drift, finger nose test –ve.

Currently:
Alert
Pulse – irregularly irregular
UL/LL – power 5/5, sensation intact
CVS - drnm
Lungs - clear

Dx –
Left MCA infarct with global aphasia,
newly diagnosed AF,
IHD

Ix:
RFT normal
TFT normal
CKMB – no raised cardiac markers
Lipids – raised TC/LDL
CBC & diff. – normal
HbA1C: 5.6%

CTB 27/11/18 – pre thrombolysis: no evidence of acute infarct or ICB. (may not be
seen on CT within first 48hrs)
CT brain 28/11/18: post thrombolysis – evolving left MCA territory infarct – well
defined hypodensities over left fronto-temporal lobe and insular cortex, sulci
effacement, no ICB
CTA brain 28/11/18 – evolving acute left MCA territory infarct

Mx/progression:

- IV digoxin 0.5mg loading given for fast AF

- IV alteplase 54mg , bolus 5.4mg given at 12.59am
- Monitor HR, keep nbm
- Fluids
- GCS/BP monitoring hourly
- CT brain
Pre thrombolysis: BP 127/81, HR 120-130 AF, GCS E3V1M5

Post thrombolysis; NIHSS 9, patient more alert/attentive, obeys command to open

and close eyes, UL/LL no drift, BP 133/74, HR 130

Throughout stay, NIHSS monitored (decreasing trend), able to answer questions –

fluent language (improved), expressive dysphasia (improved), ambulating.

Did ECHO & ECG

- LVEF 48%
- ECG - Deep T wave, no q wave at LAD territory
- Echo tro cardioembolic stroke: hypokinetic area in basal to midanteroseptal,
basal to midinferoseptal, apical septal, apical lateral, basal to apical inferior
and apical anterior wall. LA/RA normal

Day 7 in ward
- To discharge.
- Neurorehab referral. TCA neuromed D14 & repeat CT brain to start NOAC
- TCA CIHD clinic for further cardiac evaluation - angiogram
- To start single antiplatelet therapy (aspirin), cont speech therapy,
NIHSS - a quantitative measure of
stroke-related neurologic deficit