1. Gone in a Heartbeat…

2. Course in the Wards

3. 1 st Hospital Day 6/10 R occipital headache 107/59, 110, 18, 37.4 degrees C

4. 1 st Hospital Day CBC Hemoglobin109120-140 g/L Hematocrit 0.330.36-0.47 RBC 5.314.20-5.40 RBC Indices - MCV 6680-96 - MCH 2127-30 - MCHC 0.220.22-0.36 RDW-CV 12.511.5-14.5 WBC Count 9.004.5-10.03 x 10-9/L Platelet Count 260140-440 x 10-9/L Differential Count - Neutrophils 0.720.56-0.66 - Lymphocytes 0.210.22-0.40 - Monocytes 0.060.04-0.06 - Eosinophils 0.010.01-0.04

5. 1 st Hospital Day Bleeding Parameters PT1412-14 sec INR 1.09 aPTT 32.428-37 sec Clotting Time 93-25 min Bleeding Time 2.51-3 min

6. 1 st Hospital Day Electrolytes Sodium142138-146 meq/L Potassium 3.603.50-4.90 meq/L

7. 1 st Hospital Day Blood Chemistry SGPT (ALT)18.4510-40 V/L Creatinine (Blood) 0.600.51-0.95 mg/dL Urea Nitrogen 9.507.79-21.40 mg/dL

8. Chest Xray No significant findings

9. ECG Normal sinus rhythm, biatrial enlargement

10. Normal Basal Ganglia in CT Scan http://www.med-ed.virginia.edu/courses/rad/headct/

11. J.E. CT Scan

12. 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.

13. 1 st Hospital Day Assessment: cerebrovacular disease- infarct vs bleed, right middle cerebral artery Plan: Citicoline, Mannitol, Paracetamol To ACSU/ICU

14. 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

15. 2 nd Hospital Day Lipid Profile Cholesterol143.100-200 mg/dL HDL Cholesterol 43.460-59.61 mg/dL LDL Cholesterol 78.840-99.61 mg/dL Triglycerides 86.730-150.50 mg/dL VLDL 17.310-32.69 mg/dL Glucose (Fasting) 93.5270-100 mg/dL

16. Normal Basal Ganglia in MRI

17. Patient’s MRI T2 T1

18. Patient’s MRI FLAIR SWI

19. Patient’s MRI DWI ADC

20. Patient’s MRI

21. 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

22. 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.

23. 2 nd Hospital Day Assessment: Acute Hemorrhagic Infarct, R, capsuloganglionic region Plan: Secondary Stroke Prevention, Rehab

24. 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

25. Laboratory Findings 8/22/2011 – Electrolytes Potassium 3.23.50-4.90 meq/L

26. Laboratory Findings 8/22/2011 – Thyroid Function Test TSH2.710.47-4.64 vIU/mL FT3 1.981.45-3.48 pg/mL FT4 1.130.71-1.85 ng/dL

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

28. 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

29. 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

30. 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

31. 2D ECHO

32. ECG Atrial fibrillation with moderate to rapid ventricular response

35. 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

36. 5 th Hospital Day TEE

38. 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

39. 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