Summary 9

Mr. SI, a 62-year- old Malay chronic ex-smoker with underlying hypertension, type II diabetes mellitus and dyslipidemia for the past 8 years with 2 previous recurrent episodes of ischemic stroke was brought in by ambulance 1 hour later due to left-sided hemiparesis. It was of sudden onset and associated with profuse sweating followed by loss of consciousness for approximately 10 minutes.

Question: What could be the reason for "profuse sweating" in a stroke?

Otherwise, he did not have headache, dyspnea, chest pain, fever or any signs suggestive of seizure. Prior the episode, he had been experiencing dizziness on awakening and blurring of vision.

Question: What do "dizziness on awakening and blurring of vision" indicate?

He had a significant family history of stroke. His current list of medications included tablet perindopril 8 mg OD, tablet amlodipine 10 mg OD, tablet metformin/glibenclamide 500 mg/5 mg BD, subcutaneous (s/c) insulatard basal 10 units ON, tablet simvastatin 20 mg ON and tablet
aspirin 100 mg OD.

Question: What potential risk do you see in the medicines he is taking?

On examination, Mr. SI was a large built man in his 60s and was lying supine on the bed with the head of the bed tilted at 30°. He was drowsy with Glasgow coma scale (GCS) of 11/15 (E3V2M6). Left-sided facial asymmetry with drooping of the edge of the mouth towards the left side and slurring of speech were noted. He was hypertensive with blood pressure (BP) of 174/90 mmHg and was hyperglycemic with capillary blood glucose
measuring 10.2 mmol/L. Wrinkling of the forehead was preserved. Physical examination further revealed flaccid muscle tone and reduced power of both upper and lower limbs over the left side, with Medical Research Council (MRC) grade of 2/5. Extensor plantar response was positive.

Question: How do you explain the "flaccid muscle tone" in this patient who has an extensor plantar response?

Non-contrast computed tomography (CT) scan of the brain revealed multifocal infarcts with microvascular ischemia in which there were presence of hypodensities over the right central semiovale, right frontal region and right internal capsule. He was diagnosed with recurrent ischemic stroke.

Question: Which of the lesions seen on CT scan are likely to be responsible for the current neurological deficit?

On day 3 of admission, neurological examination showed rigid muscle tones with MRC of 3/5 and brisk reflexes over the left upper and lower limbs, supportive of upper motor neuron lesion. On day 5 of admission, he complained of neck pain and there was presence of neck stiffness on examination. IV tramadol 50 mg was prescribed but it did not resolve the pain. Soon, he developed fever with chills and rigors with body temperature of 38.5°C. He was tachycardic with pulse rate of 120 beats per minute. Meningitis was suspected. Lumbar puncture was offered initially but Mr. SI as well as his next of kin refused to oblige. He was then treated empirically with IV ceftriaxone 2 g immediately followed by OD and tablet paracetamol 1g QID. Blood culture and sensitivity later revealed the presence of gram negative bacilli. His condition improved with the antibiotics therapy.

Question: Why do you think he developed this complication of meningitis after a stroke? Are you saying that his stroke improved after antibiotic therapy?

Mr. SI was subsequently discharged after 9 days of admission with tablet hydrochlorothiazide 12.5 mg OD, tablet clopidogrel 75 mg OD and tablet cefuroxime 500 mg BD for 4 days. He was also advised to continue with his old medications and to resume his follow up in the appointed clinic.

Question: Why was clopidogrel given for him instead of aspirin? Why was perindopril discontinued for him? Why is it important to know the nature of his previous stroke ("2 previous recurrent episodes of ischemic stroke")?

Unless otherwise stated, the content of this page is licensed under Creative Commons Attribution-ShareAlike 3.0 License