Stroke Department Meeting

Case Conference

PGY 葛宗昀 / MA 李宗海

Presentation date: 2015/01/07

Patient Background►Name: 劉陳 X 寶►Chart No: 21411850►Age: 74 y/o►Gender: Female►Martial status: Married►Admission Date: 2014/12/23

Chief Complaint►Acute onset of left side since

2014/12/21 17:30

Present Illness ► History:

Old right MCA territory ischemic stroke Essential hypertension under medication for 7

years Type 2 diabetes mellitus under medication for 7

years First degree AV block Dyslipidemia

Present Illness ►Life activity independent before,

walking with walker►Acute left side weakness two days ago►Dizziness and left facial drooling►To TaoyuanVGH ER for help yesterday,

where no intensive survey was done. ►Vomited once in the afternoon and the

symptoms persisted. ►She was brought to our ER on 12/23.

Past & Personal History► Major disease related risk factors

Hypertension ： Yes Diabetes mellitus ： Yes Heart disease ： First degree AV block old cerebrovascular disease: Yes Hyperlipidemia: Yes

► Smoking: No► Alcohol: No► Obesity: No

Significant PE/NE findings - I► 身高 :159CM 體重 :51.1KG,

BMI:20.21► T:36.3; P:78/min; R:16/min;

BP:161/87mmHg. ► HEENT: Sclera: not icteric

Conjunctiva: not pale.► NECK:Supple, no JVE, no LAP ► Carotid bruits: R:-/L:- ► CHEST: bilateral clear► HEART: RHB without

murmur

► II. Pupil: 3/3 Light reflex: +/+ VF: normal. VA: normal.

► III,IV,VI. EOM: full► V. Corneal reflex: +/+

Pin-prick sensation: intact

► VII. Facial motor: facial palsy on left face

► VlII.Hearing: normal on Bil ear Nystagmus: no

► IX. Speech: normal Swallowing: normal Gag reflex: +/+ Uvula deviation: normal

► XI. Neck: normal► XII.Tongue protrusion:

normal Tongue atrophy: no

Significant PE/NE findings - II► Muscle power:

R upper proximal: 5 L upper proximal: 3 R upper distal: 5 L upper distal: 3 --------------------------------------- R lower proximal: 5 L lower proximal: 3 R lower distal: 5 L lower distal: 3

► Sensory: no numbness► Deep tendon reflex:

R elbow: ++ L elbow: ++ R wrist: ++ L wrist: ++ ---------------------------- R knee: ++ L knee: ++ R ankle: ++ L ankle: ++

► Babinski sign: plantar flexion / dorsiflexion► ANS: Urine- normal, Stool- normal► Cerebellar sign: F-N-F test: normal on Bil upper limbs

H-S-K test: normal on Bil-lower limbs Dysdiadochokinesia: abscent on Bil-upper limbs Muscle tone: normal on Bil-upper limbs Titubation of body: abscent

► Gait: normal

NIHSS, Barthel Index, Modified Rankin Scale

NIHSS = 51 a 0

b 0C 0

2 03 04 15 a 2

b 0

6 a 2b 0

7 08 09 010 011 0

Barthel Index = X

Modified Rankin Scale = 4

Significant Lab data► CBC/DC: 06/14 WBC: 9500 , Hb: 13.8, PLT: 290K, PTINR 1.0► Biochemistry: 06/14 BUN: 23.9, Cr: 0.85, Na: 140, K: 3.8 HbA1C: 6.9, TG: 111, LDL: 114, Cholesterol: 186 Uric acid: 6.3

Diagnosis►Favor right hemisphere ischemic

stroke

Hospital Course►Admission on 12/23►Transcranial Doppler : 12/26

Normal flow in the posterior circulation►CT of brain: 12/23

No gross ICH►MRA of Head & Neck : 12/24

Acute infarcts at right MCA and PCA territory

Old infarct at right basal ganglion High grade stenosis (>50%) at right

proximal cervical ICA

Hospital Course►Angiography 12/30

R't cervical bifucation: 57% R't V1: 75% L't P1: 70%

►Conservative treatment►Join PAC program

Thank you!!!