Wellington Case Report. Medical Report A. N 58 Yrs Male

Medical Report A. N 58 Yrs Male, Hosp No- WCA/6056/2023


02/03/2023 (02:30pm)

Background Information

Sudden onset weakness lett upper and lower limbs noticed since 02:00am about 12 hrs post ictus. Weakness progressed over the hours and on presentation he was on a wheel chair

He was fully conscious, but left lower limb was far weaker (2/5) than the left upper limb (4/5). No hemineglect suggesting no involvement of the parietal lobes.

Imaging and Diagnosis- CT below does not show any obvious territorial infarct at the moment. Hence the need to proceed to MRI Brain- stroke protacols. Meanwhile 300mg ASA given.

T1 shows strip of hypointensity on both ACA territory  which tallies with similar findings on flair sequence.

DWI/ADC mapping above confirms infarct on the ACA territory- superior frontal gyrus bilaterally. However the TOF shows an apparently normal ACA Vessels.

Management plan

1.       Admit to the ward

2.       Commence aspirin 300mg OD for 2weeks, then 75mg OD

3.       Permit hypertension for 2days except systolic greater th


5.       IV N/S 1L 8HRLY for 2days

6.       PO ROSUVASTATIN 20mg OD

7.       Monitor GCS if less than or equal to 2poinnts repeat neuro-imaging

8.       Watchout for seizures

9.       Commence physiotherapy.

Lipid profile Cholesterol shows high cholesterol 270 and low HDL.  This may have contributed to the transcient ischemic stroke. 

17 Mar, 2023
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