Hx 42RHW from home married with 2 daughters
PMHx: Viral encephalitis ~ 18 yrs ago
Bipolar disorder on mood stabilize
Anxiety
No previous Hx of: stroke, HTN, DM, MI
+smoking, occasional EtOH
Rx:
Clonazepam 1mg AM/0.5mg PM
Val.acid 500 mg a day po
Phenelzine 15mg tid po
HPI: Saturday AM, all family member decided to sleep together while watching TV in lower floor
~9 AM Pt. Walk-up with bad dream
~9:20 AM she asked her husband for a coffee and then repeatedly said "where is my daughter”
Suddenly she lay on her Lt. Sided: Lt. Weakness/incoherent to conversation/ Lt facial droop/Rt gaze deviation
EMSUA 45
minutes after the onset/no improvement .
O/E: BP 90-100/50-60, HR 78/min.RR, 99% sat.
NIHSS 19 Arousal by V.stimulai-1
LOC Q -1
LOC command-1
Force Rt gaze duction-2
Lt Homonymous hemianopsia-1
Lt upper CN VII-1
Lt motor -4 & 3
Sensory 1
Language-0
Dysarthia-2
No ataxia
Neglect-1
Extension-1
because the IV. tPA did not restore the flow in med.cerebral artery we decided to go for intra-arteria tPA
before the treatmnt also trans dopplar ultrasound did show M1 low but the patient remain weak on Lt sided !
after IA. tPA
blood flow now restored and patient improved but had iheamorrahge in basal ganglia (artery of Hubenar) acceptable than total MCA infaction.
end results:
NIHSS 3
Mild Dysarthia/Lt arm drift/Lt facial droop
please dont copy these case without my permission.
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مواقع النشر (المفضلة)