You are on page 1of 13

1

Patient Profile

53 53 kg 160 cm

CC: 3
PI:
7.35 . 3
trauma refer
ER
PH: U/D Hyperthyroid 2
FH:
MH: PTU (50) 1x2 oral pc
Propranolol (10) 1x1 oral pc
SH: 10
ALL:
PE: T 36.2 C PR 108/min RR 16/min BP 142/82 mmHg DTX 134 mg/dL
GA: A middle aged male, good conscious
HEENT: not pale, no jaundice, carotid bruit negative
Heart: normal S1S2, no murmur and regular HR
ECG: sinus tachycardia
Lung: clear
Abdomen: mild tender, soft and no guarding
Neuro exam: E4V5M6, pupil 3mm RTLBE, left facial palsy UMN, no tongue deviation
Clonus positive at left and negative at right
CT brain: Effacement and right frontotemporal sulci and loss of ribbon sign of right
insular cortex, suspected hyperacute cerebral infarction and acute right cerebellar
infarction
-No hemorrhagic transformation (14/11/2558)
Echo: Normal LV size and systolic function and normal valve structure, impared LV
relaxation, normal echo study for age
PT note (16/11/2558): left hemiparesis
Impression: Acute ischemic stroke
Vital signs
Date

14/11/2558 15/11/2558 16/11/2558 17/11/2558 18/11/2558

T ()

37.7

38.3

38.1

37

36.8

PR (/min)

108

112

98

80

90

RR (/min)

22

16

16

22

20

BP (mmHg)

187/98

167/95

194/92

152/82

148/117

water intake (mL)

1800

2400

850

1000

300

water output (mL)

1800

2000

1300

2000

600

Blood chemistry
Blood Chemistry

Reference range 14/11/2558 15/11/2558

Glucose NaF (mg/dL)

74-109

100

serum creatinine (mg/dL)

0.70-1.20

0.44

eGFR (mL/min/1.73m2)

>= 90

129.48

HDL-Cholesterol

>55

72

LDL-Cholesterol (mg/dL)

<150

104

cholesterol (mg/dL)

<200

178

triglyceride (mg/dL)

<200

62

4.8 -5.9

5.5

Hb A1c
A1c

0.7

Total Hb

18.8

sodium (mmol/L)

136-145

137

potassium (mmol/L)

3.5-5.1

3.35

Cholride (mmol/L)

98-107

96

CO2 (mmol/L)

22-29

22.3

CBC
CBC
WBC (10^3/uL)

Reference Range 14/11/2558


4.5-10.0

7.7

3.98

RBC (10^6/uL)

4.5-6.30

5.28

Hemoglobin (g/dL)

13.0-17.4

15.2

Hematocrit (%)

40-54

43.7

MCV (fL)

80-98

83

MCH (pg)

25.2-32.0

28.8

MCHC (g/dL)

31.3-33.4

34.8

RDW (%)

11.9-14.8

13.8

PLT (10^3/uL)

140-440

270

Neutrophil %

43.7-70.9

55.6

Lymphocyte %

20.1-44.5

32.9

Monocyte %

3.4-9.8

6.4

Eosinophil %

0.7-9.2

4.8

Basophil %

0.0-2.6

0.3

Coagulation
Coagulation

Reference range 14/11/2558

Prothrombin time

10.8-13.6

10.7

INR

0.8-1.2

0.91

Partial thromboplastin time 26.8-41.6

Thyroid

30.3

Reference range 15/11/2558

Free T4 (ng/dL) 0.93-1.70

2.51

Free T3 (pg/mL) 2.00-4.00

10.06

TSH (mIU/L)

<0.005

Urinalysis

0.27-4.20

Reference range

17/11/2558

volume

5 - 10

10

color

Yellow

Yellow

clarity

Clear

Clear

pH

Sp.Gr.

1.014

Protein

Negative

Negative

Glucose

Negative

1+

ketone

Negative

positive

Blood

Negative

Negative

Nitrite

Negative

Negative

Urobilinogen

Normal

Normal

Bilirubin

Negative

Negative

Leukocyte

Negative

Negative

RBC

<=5

0-1

WBC

<=5

0-1

Squamous epith
Bacteria

0-1
Occasion

Drug&dosage regimen
(continue)

14/11/2558 15/11/2558 16/11/2558 17/11/2558 18/11/2558

E.KCl 30ml oral q3h x 3 dose

ASA grV 1x1 oral pc

simvastatin (20) 1x1 oral hs

Omeprazole (20) 1x1 oral ac

/
/

off

Folic acid 1x1 oral pc

Thiamine 100mg IV OD

VitB complex 1x3 oral pc

PTU 2x3 oral pc


Propranolol (10) 1x2 oral pc

enoxaparin 0.6ml SC q12h

Ceftriaxone 2g IV OD with stat

Warfarin (3) 1x1 oral hs

Rantidine (50) 1x2 oral pc

Home medication
1. PTU 2x3 oral pc
2. Propranolol (10) 1x2
3. Warfarin (3) 1x1 oral hs
4. Ranitidine (50) 1x2 oral pc
5. Simvastatin (20) 1x1 oral hs
6. Bcomplex 1x2 pc
7. Folic acid 1x1 oral pc
8. Omnicef (cefdinir) (100) 2x2 oral pc #20
SOAP note

Problem: Acute ischemic stroke


S: 53 53 3
ER
10
PTU (50) 1x2 oral pc Propranolol
(10) 1x1 oral pc
O: PE: T 36.2 PR 108/min RR 16/min BP 142/82 mmHg DTX 134 mg/dL
GA: A middle aged male, good conscious
Neuro exam: E4V5M6, pupil 3mm RTLBE, left facial palsy UMN, no tongue deviation
Clonus positive at left and negative at right
CT brain: Effacement and right frontotemporal sulci and loss of ribbon sign of right insular
cortex, suspected hyperacute cerebral infarction and acute right cerebellar infarction
-No hemorrhagic transformation (14/11/2558)
Vital signs

14/11/2558 15/11/2558 16/11/2558 17/11/2558 18/11/2558

T ()

37.7

38.3

38.1

37

36.8

PR (/min)

108

112

98

80

90

RR (/min)

22

16

16

22

20

BP (mmHg)

187/98

167/95

194/92

152/82

148/117

water intake (mL)

1800

2400

850

1000

300

water output (mL)

1800

2000

1300

2000

600

Blood Chemistry

Reference range 14/11/2558 15/11/2558

Glucose NaF (mg/dL)

74-109

100

serum creatinine (mg/dL)

0.70-1.20

0.44

eGFR (mL/min/1.73m2)

>= 90

129.48

HDL-Cholesterol

>55

72

LDL-Cholesterol (mg/dL)

<150

104

cholesterol (mg/dL)

<200

178

triglyceride (mg/dL)

<200

62

4.8 -5.9

5.5

Hb A1c
A1c

0.7

Total Hb

18.8

sodium (mmol/L)

136-145

137

potassium (mmol/L)

3.5-5.1

3.35

Cholride (mmol/L)

98-107

96

CO2 (mmol/L)

22-29

22.3

Drug&dosage regimen (continue)

14/11/2558

E.KCl 30ml oral q3h x 3 dose

ASA grV 1x1 oral pc

simvastatin (20) 1x1 oral hs

Omeprazole (20) 1x1 oral ac


VitB complex 1x3 oral pc
Drug&dosage regimen (cont.)

3.98

15/11/2558

16/11/2558

17/11/2558

18/11/2558

/
/

off

14/11/58

15/11/58

16/11/58

17/11/58

18/11/58

Folic acid 1x1 oral pc

Thiamine 100mg IV OD

PTU 2x3 oral pc


Propranolol (10) 1x2 oral pc

enoxaparin 0.6ml SC q12h

Ceftriaxone 2g IV OD with stat

Warfarin (3) 1x1 oral hs

Rantidine (50) 1x2 oral pc

A: Etiology:

(neurological deficit)
24

2 1.Ischemic stroke 2.Hemorrhagic stroke
ischemic stroke 85
1. Ischemic stroke (thrombus)
2
1.1 atherosclerosis plaque
Thrombotic Stroke thrombosis
thrombosis
Lacunar infarction
1.2
cardiogenic embolism

2. Hemorrhagic stroke 3

2.1 Subarachnoid hemorrhage subarachnoid space


aneurysm

2.2 Intracerebral hemorrhage


ventricle subarachnoid
. 2.3 Subdural hematomas dura arachnoid

Risk factor
ischemic stroke
CHF, LVH, AF

1. (Nonmodifiable Risk Factors) (>)



2. (Modifiable Risk Factors)
-
-
fibrinogen HDL

- atrial fibrillation

- Transient ischemic attacks (T.I.A.s)
-
2-4
- Cholesterol LDL Cholesterol
- (atherosclerosis) Carotid artery

10

hyperthyroid
Sheu JJ. hyperthyroid 5
stroke hyperthyroid ischemic stroke
1.44 (95% CI, 1.022.12;P=0.038)

-

-
-
-
-
Assessment of Therapy


Neurological sign E4V5M6 Glasgow coma scale 15
NIH stroke scale 2 minor stroke modified rankin
scale 4
CT brain old infarction at right cerebellum brain swelling at
right parietal and frontal lobe Ischemic stroke
AHA/ASA guideline 2013 Acute
ischemic stroke 24 2
1. Acute phase ()
2. Reperfusion phase ()
acute phase
1. Supplemental Oxygen and airway Support
2. Temperature
hyperthermia (body temperature >38C)
source of infection empiric antibiotics
3. Intravenous Fluids (IV NSS) D5W
4. Glucose metabolism
Hypoglycemia (blood glucose <60 mg/dL) 25ml 50% dextrose
slow IV push 140-180 mg/dL 80-140 mg/dL

5. Hypertension

11

TIA acute ischemic stroke


- BP > 220/120 mmHg
- rt-PA BP > 185/110 mmHg rt-PA

- BP < 185/110 mmHg rt-PA


systolic BP > 180230 mmHg diastolic BP >105120 mmHg
- Labetalol 10 mg IV followed by continuous IV infusion 28 mg/min
- Nicardipine 5 mg/h IV, titrate up to desired effect by 2.5 mg/h every 515 min, max
15 mg/h
- BP BP >140 mmHg IV sodium nitroprusside
Goal: BP 15-25% 24 stroke
reperfusion phase
1. Thrombolytic drugs
- Recombinant tissue plasminogen activator (rtPA)
acute ischemic stroke 0.9 mg/kg ( 90
mg) IV bolus 10%, IV infusion 90% 60 4.5

Thrombolytic drugs

1. bacterial endocarditis
2. 3
3. 3
4. hemorrhagic stroke
5. (major surgery) 14 (minor surgery) 10
(lumbar puncture)
6.
7. 21
8. hemodialysis
9. PTT > 40 , INR > 1.5 (platelet count) < 100,000
/
10. SBP > 185 , DBP > 110
11.
12. < 50 > 400

2. (Anticoagulant)
3. (Antiplatelet drug)
rtPA stroke 4.5
Secondary prevention

12

1.) Cardioembolic (esp. atrial fibrillation); Warfarin


- ischemic stroke cardioembolism
INR 2-3 ASA
- warfarin ASA stroke intracranial stenosis

warfarin noncardioembolism
2.)
Stroke
3.)
P:
Goal of therapy
- stroke
- ( stroke)
- mortality
- stroke TIA
- INR 2-3
Therapeutic plan
- Warfarin (3) 1x1 oral hs
- Ranitidine (50) 1x2 oral pc
- Simvastatin (20) 1x1 oral hs
- Bcomplex 1x2 pc
- Folic acid 1x1 oral pc
Efficacy monitoring
- INR 2-3
- INR, PTT, PT
- Vital signs, GCS
- IICP

Safety monitoring
- Warfarin: bleeding, pruritus, taste disturbance
- Simvastatin: elevate CPK, URI, flatulance, abdominal pain,
- Folic acid: rash, slight flushing
- Vitamin B complex: diarrhea, constipation, allergic reaction

13

- Ranitidine: headache, constipation, N/V, hypersensitivity


Education
1. ischemic stroke
-
-
-

-
-
-
-
-
-
-
-
-
-

Reference
1. .. .
. ; 14-21
2. Lacy CF, Armstrong LL, Goldman MP and Lance LL. Eds. Drug information
handbook.20th ed. Ohio: Lexicomp. 2011
3. .
.
4. . .