60 years old, malay lady

with underlying hypertension for 1 year, not on regular treatment/follow up

- had history of visiting GP 3 days prior to admission for hypertensive urgencies with BP ~ 210/120. How-
ever, not keen for admission. Given oral med and bp came down. During the episode, patient complained of
blurry of vision. No headache, body weakness, chest pain, SOB.

She presented to ED with acute onset right sided upper and lower limb weakness for 2 days, associated with
blurry vision, facial asymmetry and slurred speech. She denied history of fall, trauma, episodes of body
weakness in the past, headache, palpitations. After the onset of weakness, she is able to tolerate orally with
no choking episode, no bowel or urinary incontinence.

She complained of having central chest discomfort, tightness in nature associated with minimal shortness of
breath lasted for a few minutes in the past two days. The discomfort did not radiate to anywhere else, not ac-
companied with diaphoresis, palpitation, nausea or vomiting. She never seek medical help for that.

Otherwise, she denied history of covid contact, URTI symptoms, fever. No LOA, LOW. Bowel movement
normal. No abnormal postmenopausal bleeding.

Social hx: She’s married and blessed with a son. She’s currently staying with husband who is healthy, in a
double storey house. There is room at the ground floor with sitting toilet available. Walking aid is available
at home. She has good family support.

Patient does not smoke or drink alcohol.

No history of surgery.
She achieved menopause at age 40s.

At ED, BP on arrival 171/88 , PR 102, regular rhythm, RR 20, Spo2 95% RA, Afebrile
DXT 13.6 post meal - s/c Actrapid given - 8.9

o/e:
Loss of nasolabial over right, power over right UL and LL 3/5, plantar reflexes downgoing. No clonus.
Gag reflexes present.
CVS DRNM, no carotid bruits

DX
1. CVA with right hemiparesis secondary to hypertensive emergencies
2. ACS (Unstable angina/NSTEMI) secondary to hypertensive emergencies

DDX
1. TRO ICB secondary to hypertensive emergencies
2. Myocardiac infarction
3. Pneumonia
4. Acute Pericarditis
5. Gastritis
6. Cerebral abscess
7. Brain tumour/brain mets
IX

Blood
FBC
COAG
RP
CAMGPO4
Troponin I - specific for myocardial injury may not raise if less than 6 hours, so can repeat, will persist for
5-14 days
CK - less sensitive than trop i

TO LOOK FOR AETIOLOGY OF STROKE -

FSL - LDL target < 1.8, if low risk is 3.4
FBS

Micro
UFEME - UTI, proteinuria due to uncontrolled hot

Imaging
CXR - cardiomegaly, pneumonia, covid 19.

ECG - to look for evidence of AF which can cause stroke due to cardio emboli. also to look for abnormal
changes such as ST elevation/depression, evidence of previous infarct Q wave, T inversion.

CT BRAIN - TO DIFFERENTIATE HAEMORRHAGE FROM ISCHEMIA, DETERMINE SITE, CAUSE

AND EXTENT OF LESIONS

ECHO - assess LV systolic function, assess cardiac function, valvular dysfunction also rule out cardio em-
bolism, assess regional wall motion abnormalities due to MI

MX
1. Oxygen and airway, keep spo2 95
2. MONITOR VITAL SIGNS, BP HOURLY, do not treat if systolic BP < 220/120
iv labetolol 20mg stat.
3. GCS/PUPIL CHARTING
4. DXT MONITORING - keep 6-10. avoid hypoglycemia.
5. CT BRAIN URGENT
6. TRACE IX
7. Swallowing test - NG TUBE if failed
8. Early mobilization
9. TED STOCKING FOR DVT THROMBOPROPHYLAXIS
10. if no ICB, start antiplatelet in view of stroke, but pt got nstemi, so need to start DAPT + arixtra(fonda) 5
days. *** LMWH clexane
11. T aspirin 300mg stat then 75mg OD, S/l gtn 1/1 prn, t. plavix 300mg stat and 75mg od,
12. iv morphine 5mg stat for pain relief
13.

TIMI risk score

Stoke - clinical syndrome characterised by rapidly developing clinical mptoms or signs of focal/global loss
of cerebral function with sx lasting for more than 24 hrs or leading t death, win no apparent cause other than
that of vascular origin

TIA - acute loss of focal cerebral function with sx lasting less than 24 hours, which is thought due to be inad-
equate cerebral and ocular blood supply as a result of arterial thrombosis or embolism.

Cause ( ASCO)
ATHEROTHROMBOSIS OF LARGE VESSELS
INTRACRA-
NIAL SMALL
VESSEL DIS-
EASE - lacunar
infarct due to
occlusion of
small perforat-
ing arteries
CARDIAC
CAUSE - car-
dioemboli com-
mon cause,
must rule out.
OTHER
CAUSE
Assess stroke activity
NIHSS SCALE
MRS SCALE

AF - CHA2DS2-VASC , >=2 start warfarin

Complications of STEMI
1. Arrhythmia - VT, AF, Bradycardia ( 1st,2nd 3rd degree block), asystole, PEA

2. LV dysfunction and shock - KILLIP

3. mechanical complications - wall rupture, ventricular septal rupture, mitral regurgitation
4. RV infarction
5. Pericarditis - Dressler syndrome (immunological mediated)
Thrombolytic therapy - Reperfusion of ischemic brain
- IV Alteplase if 4.5hrs from onset
- endovas-
cular
thrombec-
tomy
within 6
hours