Case for Discussion

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14 Jul 2016 - General

55 years old gentlleman, with background history of hypertension, hypercholesterolaemia, attended emergency department with sudden on-set of left sided weakness,left facial droop, with the onset time of around 2 hours ago. Patient is on medications for his hypertension and hypercholesterolol, compliance was not great, Patient experienced left sided weaknes with facial droop, when he working in his shop, and was witnessed by his wife, On examination, patient has left facial droop, with power of left upper limb of 2, and left lower limb of 3, with dysmetria, sensory and visual inattention, minimal dysarthria. What is the potential working diagnosis and differential diagnosis for this patient ?? Is it a medical emergency that warrant urgent/immediate investigation and intervention???  What will be the subsequent management plan ?? Prognosis??

Hi You Yi. There is no doubt that this is an emergency. Although the Glasgow coma scale is not mentioned, I will still consider this patient as a top priority if he presents to me at the ER. My presumptive diagnosis is a Malignant infarct of the right internal carotid artery since aside from middle cerebral artery territory symptoms, you mentioned posterior cerebral circulation findings (visual inattention). Dysmmetria is non contributory to this case because cerebellar testing is not reliable i...
 (Total 188 words)
Yes, this patient has a clinical diagnosis of stroke. As the time of onset is 2 hours (less than 4.5 hours), an urgent CT-Brain +/- CT-Angiogram (depend on whether the centre would offer the thrombectomy procedure), need to be done to ensure it was not a haemorrhagic stroke. Thrombolysis with tPA, will be given to this patient if the CT-Brain result was normal (can be normal as sometime the infarction will take some time to show up on CT, and stroke is clinical diagnosis !!!!) or showed acute ...
 (Total 118 words)
I would use the ACLS protocol on this patient. Consider Ischemic vs. Hemorrhagic Stroke and have a non-contrast CT scan. Determine the presence of hemorrhage. If with hemorrhage refer to neurosurgeon if without check for fibrinolytic exclusions and repeat neurologic examination for change in deficits. If with no contraindications give fibrinolytic therapy and admit to ICU for close monitoring. That is my general view for this patient. Prognosis would depend on the time it took to treat the patie...
 (Total 90 words)