Gone in a Heartbeat…

Course in the Wards

1st Hospital Day6/10 R occipital headache107/59, 110, 18, 37.4 degrees C

1st Hospital Day

CBCHemoglobin 109 120-140 g/L

Hematocrit 0.33 0.36-0.47

RBC 5.31 4.20-5.40

RBC Indices    

- MCV 66 80-96

- MCH 21 27-30

- MCHC 0.22 0.22-0.36

RDW-CV 12.5 11.5-14.5

WBC Count 9.00 4.5-10.03 x 10-9/L

Platelet Count 260 140-440 x 10-9/L

Differential Count    

- Neutrophils 0.72 0.56-0.66

- Lymphocytes 0.21 0.22-0.40

- Monocytes 0.06 0.04-0.06

- Eosinophils 0.01 0.01-0.04

1st Hospital Day

Bleeding Parameters

PT 14 12-14 sec

INR 1.09  

aPTT 32.4 28-37 sec

Clotting Time 9 3-25 min

Bleeding Time 2.5 1-3 min

1st Hospital Day

Electrolytes

Sodium 142 138-146 meq/L

Potassium 3.60 3.50-4.90 meq/L

1st Hospital Day

Blood ChemistrySGPT (ALT) 18.45 10-40 V/L

Creatinine (Blood) 0.60 0.51-0.95 mg/dL

Urea Nitrogen 9.50 7.79-21.40 mg/dL

Chest Xray

• No significant findings

ECG

Normal sinus rhythm, biatrial enlargement

Normal Basal Ganglia in CT Scan

http://www.med-ed.virginia.edu/courses/rad/headct/

J.E. CT Scan

Patient’s CT Scan Report

• Isodense focus in the right capsuloganglionic region

• Maybe secondary to a mass lesion, less likely a subacute hemorrhage.

• A contrast enhanced CT or MRI study is suggested

• Rightward nasal septal deviation.

1st Hospital Day

Assessment: cerebrovacular disease- infarct vs bleed, right middle cerebral artery

Plan: Citicoline, Mannitol, ParacetamolTo ACSU/ICU

2nd Hospital Day

intermittent HA 3/10110/60, 90, 20, 37.9CMotor: 3/5 on the left, 5/5 on the rightSensory: 80 % on the left

2nd Hospital Day

Lipid Profile

Cholesterol 143.10 0-200 mg/dL

HDL Cholesterol 43.46 0-59.61 mg/dL

LDL Cholesterol 78.84 0-99.61 mg/dL

Triglycerides 86.73 0-150.50 mg/dL

VLDL 17.31 0-32.69 mg/dL

Glucose (Fasting) 93.52 70-100 mg/dL

Normal Basal Ganglia in MRI

Patient’s MRIT2T1

Patient’s MRIFLAIR SWI

Patient’s MRIDWI ADC

Patient’s MRI

Patient’s MRI/MRA Report

• Acute hemorrhagic infarct, right posterior capsuloganglionic region and corona radiata without significant midline shift

• Consider a tiny acute non-hemorrhagic infarct in the left extreme capsule

• No abnormal areas of contrast enhancement• No hydrocephalus at this time• No obvious aneurysmal dilatation, stenosis, or

abnormal tangle of vessels

MRI/MRA• Acute hemorrhagic infarct, right posterior

capsuloganglionic region and corona radiate without significant midline shift.

• Consider a tiny acute non-hemorrhagic infarct in the left extreme capsule.

• No abnormal areas of contrast enhancement. No hydrocephalus at this time.

• Unremarkable MRA study• No obvious aneurismal dilatation, stenosis or

abnormal tangle of vessels.

2nd Hospital Day

Assessment: Acute Hemorrhagic Infarct, R, capsuloganglionic region

Plan: Secondary Stroke Prevention, Rehab

3rd Hospital Day2/10 intermittent HAMotor: 3/5 left , able to move left thumb Sensory: 80% leftReferred to cardio due to murmur on pehistory of easy fatigability climbing 2 flights of stairs110/70, 80, 20, afebrileJVP 3cmApex beat 5th ICS MCLR Ventricular HeavePalpable ThrillLoud S1 opening snapincreased P2 componentat least grade 4 Diastolic murmur

Laboratory Findings

• 8/22/2011 – Electrolytes

Potassium 3.2 3.50-4.90 meq/L

Laboratory Findings

• 8/22/2011 – Thyroid Function Test

TSH 2.71 0.47-4.64 vIU/mL

FT3 1.98 1.45-3.48 pg/mL

FT4 1.13 0.71-1.85 ng/dL

• ASO 144 (0-200) • ESR 27 (0-20)• iCA, Mg – Normal• Lipid Profile – Normal• ECG – Sinus rhythm

3rd Hospital Day

Assessment: Mitral Stenosis probably secondary to RHDNYHA functional class IIAcute Hemorrhagic infarct R capsuloganglionic region

Plan: Penicillin 1.2 million units IMIvabradine 5mg/tab BID as needed

4th Hospital Day

No headache104/58, 83, 20, afebrileMotor: 4/5 LUE, 3/5 LLEable to move thumb and fingersSensation: 90% on LUE and LLE

2D ECHO• Rheumatic heart disease with severe mitral stenosis,

aortic sclerosis, and possible tricuspid sclerosis with moderate-severe tricuspid regurgitation.

• Pulmonary hypertension• Left atrial enlargement with probable atrial thrombi• Normal left ventricular size and contractility• Estimated systolic pulmonary artery pressure

52mmHg by TR jet

2D ECHO

ECG

• Atrial fibrillation with moderate to rapid ventricular response

Assesment: Cerebrovascular disease - infarct, right MCA, probably

cardioembolic with hemorrhagic conversionValvular Heart Disease, Dilated left atrium, Severe mitral stenosis, mild tricuspid regurgitation probably secondary to Rheumatic heart disease Paroxysmal Atrial Fibrillation with Rapid Ventricular ResponseCongestive Heart failure, NYHA Functional Class II

Plan: Verapamil, Amiodarone

5th Hospital Day

TEE

TEE

TEE

• Severe mitral stenosis with MVA 0.7-0.8cm2 mean gradient 18-20 mmHg

• Dilated left atrium• Positive spontaneous echo contrast, no

thrombus visualized• Mild tricuspid regurgitation

Assessment: Cerebrovascular disease - infarct, right MCA, probably

cardioembolic with hemorrhagic conversionValvular Heart Disease, Dilated left atrium, Severe mitral stenosis, mild tricuspid regurgitation probably secondary to Rheumatic heart disease Paroxysmal Atrial Fibrillation with Rapid Ventricular ResponseCongestive Heart failure, NYHA Functional Class II

Plan: Atenolol