Gone in a Heartbeat…

Course in the Wards

1 st Hospital Day 6/10 R occipital headache 107/59, 110, 18, 37.4 degrees C

1 st Hospital Day CBC Hemoglobin g/L Hematocrit RBC RBC Indices - MCV MCH MCHC RDW-CV WBC Count x 10-9/L Platelet Count x 10-9/L Differential Count - Neutrophils Lymphocytes Monocytes Eosinophils

1 st Hospital Day Bleeding Parameters PT sec INR 1.09 aPTT sec Clotting Time min Bleeding Time min

1 st Hospital Day Electrolytes Sodium meq/L Potassium meq/L

1 st Hospital Day Blood Chemistry SGPT (ALT) V/L Creatinine (Blood) mg/dL Urea Nitrogen mg/dL

Chest Xray No significant findings

ECG Normal sinus rhythm, biatrial enlargement

Normal Basal Ganglia in CT Scan

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.

1 st Hospital Day Assessment: cerebrovacular disease- infarct vs bleed, right middle cerebral artery Plan: Citicoline, Mannitol, Paracetamol To ACSU/ICU

2 nd Hospital Day intermittent HA 3/10 110/60, 90, 20, 37.9C Motor: 3/5 on the left, 5/5 on the right Sensory: 80 % on the left

2 nd Hospital Day Lipid Profile Cholesterol mg/dL HDL Cholesterol mg/dL LDL Cholesterol mg/dL Triglycerides mg/dL VLDL mg/dL Glucose (Fasting) mg/dL

Normal Basal Ganglia in MRI

Patient’s MRI T2 T1

Patient’s MRI FLAIR SWI

Patient’s MRI DWI 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.

2 nd Hospital Day Assessment: Acute Hemorrhagic Infarct, R, capsuloganglionic region Plan: Secondary Stroke Prevention, Rehab

3 rd Hospital Day 2/10 intermittent HA Motor: 3/5 left, able to move left thumb Sensory: 80% left Referred to cardio due to murmur on pe history of easy fatigability climbing 2 flights of stairs 110/70, 80, 20, afebrile JVP 3cm Apex beat 5 th ICS MCL R Ventricular Heave Palpable Thrill Loud S1 opening snap increased P2 component at least grade 4 Diastolic murmur

Laboratory Findings 8/22/2011 – Electrolytes Potassium meq/L

Laboratory Findings 8/22/2011 – Thyroid Function Test TSH vIU/mL FT pg/mL FT ng/dL

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

3 rd Hospital Day Assessment: Mitral Stenosis probably secondary to RHD NYHA functional class II Acute Hemorrhagic infarct R capsuloganglionic region Plan: Penicillin 1.2 million units IM Ivabradine 5mg/tab BID as needed

4 th Hospital Day No headache 104/58, 83, 20, afebrile Motor: 4/5 LUE, 3/5 LLE able to move thumb and fingers Sensation: 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 conversion Valvular Heart Disease, Dilated left atrium, Severe mitral stenosis, mild tricuspid regurgitation probably secondary to Rheumatic heart disease Paroxysmal Atrial Fibrillation with Rapid Ventricular Response Congestive Heart failure, NYHA Functional Class II Plan: Verapamil, Amiodarone

5 th Hospital Day TEE

Severe mitral stenosis with MVA cm2 mean gradient mmHg Dilated left atrium Positive spontaneous echo contrast, no thrombus visualized Mild tricuspid regurgitation

Assessment: Cerebrovascular disease - infarct, right MCA, probably cardioembolic with hemorrhagic conversion Valvular Heart Disease, Dilated left atrium, Severe mitral stenosis, mild tricuspid regurgitation probably secondary to Rheumatic heart disease Paroxysmal Atrial Fibrillation with Rapid Ventricular Response Congestive Heart failure, NYHA Functional Class II Plan: Atenolol