Notes

ON 12/07/2017:
a 52 year old Indian male patient, know case of:
-DM- last Hba1c was 8.1- not taking medications since last 4

months.
-HTN.

Brought by his son to ED on 12/7/2017 because of aphasia.
The patient woke up 2 days ago with inability to speak, and

inability to comprehend speech.
He was confused and fatigued.

CT Head was done and showed Hypodensity noted involving the left

parasagittal grey matter and also periventricular white matter.
Subtle buckling of the interhemispheric fissure to the right is

noted.

ON 13/07/2017:
seen by neurology department and they suspected hyper osmolar

state unmasking old ischemic event
and their plan was to do MRI for further evaluation of CT and rule

out new ischemic event
start Aspirin 100 mg po once daily
high intensity statin
good hydration (start normal saline )
PT/OT/SP

admitted under team 1A medicine and the plan wasL
-to do MRI Head, Echocardiogram, Holter, carotid doppler
HBA1c, Lipid profile
- start DVT prophylaxis Enoxaparin
ASA 100 mg PO OD, Atorvastain 40 mg PO OD , Insulin Sliding scale
-PT,OT,Rehab, swallowing assessment (swallow assessement

done,pass)


Echocardiography was done

• Normal global systolic LV function (EF 60 %).
• No regional wall motion abnormality.
• Normal diastolic LV function.
• Normal RV function.
• No evidence of a patent foramen ovale.



transfered to stroke unite


ON 14/07/2017:
MRI Head, MRA Head and neck where done and showed :
Left frontal cortical and subcortical parasagittal recent

infarction along the left ACA territory which is totally occluded

at its A2 segment.
Left thalamic and right lentiform nucleus chronic lacunar

infarctions.
Diffuse brain cortical involutional changes.
Atherosclerotic changes most prominent at the proximal courses of

the posterior cerebral arteries.
Unremarkable MRA of the neck arteries

seen by stroke unite and the plan was to as follows:
DAPT for 3 months with atorvastin
Gradual control of BP with with long term range <140/90
Good DM control and Education
Secondary stroke prevention
PT/OT/Rehab
and also to start low dose ACEI as MRA neck is normal

on the same day his right lower limb power deteriorated so

antihypertensives have been held
and he recieved 75 ml/ns and urgent CT Head was done which showed

:
The hypodensity which was seen on the previous CT scan dated 12

July 2017 is still the same in the left parasagittal grey matter

and periventricular white matter.
Mild mass effect on the left anterior horn of the lateral

ventricle. The ventricular system otherwise appear unremarkable.
No intracranial haemorrhage seen.

seen again by neurology department and their Plan was : Bed rest.

IV NS for hydration, management of BP if goes above 200 systolic.
He improved.


ON 15/07/2017:
patient was kept on prn labetalol in case of BP more than 200/100
he was stable apart of high random blood sugar readings
insulin aspart fixed12units

ON 16/07/2017:
patient is awake, mildly drowsy and reply in single words , obeys

commands there is weakness in the left lower limb, he was able to

walk with assistance
the plan was to monitor RBS level
continue rehabilitation and PT

ON 17/07/2017:
patient is constipated, his BP on the higher side as recommended

by neurologist, and his power on the left side is improving but

still has some abnormal RBS readings
decrease Glargine dose from 15 unites to 12 unites
increase morning aspart insuline dose to 10
continue monitoring RBS
movicol BID for constipation

on the same day the assigned nurse called saying that the patient

is complaining of toothache .. i went to see the patient ..

according to his son the patient had the same pain for 15 days now

and he is taking analgesic (tabs) for it .. the patient is

complaining of pain at the second right lower molar tooth .
patient was given start diclofenac potassium 50mg BID
referral to oral maxillofacial surgery

ON 17/07/2017:
patient is well, improving ( now he can move to bathroom without

someone assistance ( holds on furnitures), the toothache markedly

decreased, had 3 bowl motions no new complaints.

assessed by the stroke unite and there Plan:
continue antipatelets /statin
can be discharged after occupational evaluation
follow up in stroke clinic after 6 weeks

assessed by the rehabilitation DR.ASHRAF according to him the

patient has a risk of fall
and they will reassess him later on
the plan was to:
continue monitoring RBS
movicol PRN
rehabilitation assessment

later on he was assessed by Occupational Therapy and
Patient sleepy,slow /delayed response
Poor activity participation
Eating with minimal assistence
refused for functional walking

Plan:
Right upper limb strengthening
Orientation training to place ,time
Transfer and functional walking training