1. Stroke Department Meeting Case Conference PGY 葛宗昀 / MA 李宗海 Presentation date: 2015/01/07

2. Patient Background ► Name: 劉陳 X 寶 ► Chart No: 21411850 ► Age: 74 y/o ► Gender: Female ► Martial status: Married ► Admission Date: 2014/12/23

3. Chief Complaint ► Acute onset of left side since 2014/12/21 17:30

4. Present Illness ► History:  Old right MCA territory ischemic stroke  Essential hypertension under medication for 7 years  Type 2 diabetes mellitus under medication for 7 years  First degree AV block  Dyslipidemia

5. Present Illness ► Life activity independent before, walking with walker ► Acute left side weakness two days ago ► Dizziness and left facial drooling ► To TaoyuanVGH ER for help yesterday, where no intensive survey was done. ► Vomited once in the afternoon and the symptoms persisted. ► She was brought to our ER on 12/23.

6. Past & Personal History ► Major disease related risk factors  Hypertension ： Yes  Diabetes mellitus ： Yes  Heart disease ： First degree AV block  old cerebrovascular disease: Yes  Hyperlipidemia: Yes ► Smoking: No ► Alcohol: No ► Obesity: No

7. Significant PE/NE findings - I ► 身高 :159CM 體重 :51.1KG, BMI:20.21 ► T:36.3; P:78/min; R:16/min; BP:161/87mmHg. ► HEENT: Sclera: not icteric Conjunctiva: not pale. ► NECK:Supple, no JVE, no LAP ► Carotid bruits: R:-/L:- ► CHEST: bilateral clear ► HEART: RHB without murmur ► II. Pupil: 3/3 Light reflex: +/+  VF: normal.  VA: normal. ► III,IV,VI. EOM: full ► V. Corneal reflex: +/+  Pin-prick sensation: intact ► VII. Facial motor: facial palsy on left face ► VlII.Hearing: normal on Bil ear  Nystagmus: no ► IX. Speech: normal  Swallowing: normal  Gag reflex: +/+  Uvula deviation: normal ► XI. Neck: normal ► XII.Tongue protrusion: normal  Tongue atrophy: no

8. Significant PE/NE findings - II ► Muscle power:  R upper proximal: 5 L upper proximal: 3  R upper distal: 5 L upper distal: 3  ---------------------------------------  R lower proximal: 5 L lower proximal: 3  R lower distal: 5 L lower distal: 3 ► Sensory: no numbness ► Deep tendon reflex:  R elbow: ++ L elbow: ++  R wrist: ++ L wrist: ++  ----------------------------  R knee: ++ L knee: ++  R ankle: ++ L ankle: ++ ► Babinski sign: plantar flexion / dorsiflexion ► ANS: Urine- normal, Stool- normal ► Cerebellar sign: F-N-F test: normal on Bil upper limbs  H-S-K test: normal on Bil-lower limbs  Dysdiadochokinesia: abscent on Bil-upper limbs  Muscle tone: normal on Bil-upper limbs  Titubation of body: abscent ► Gait: normal

9. NIHSS, Barthel Index, Modified Rankin Scale NIHSS = 5 1a0 b0 C0 20 30 41 5a2 b0 6a2 b0 70 80 90 100 110 Barthel Index = X Modified Rankin Scale = 4

10. Significant Lab data ► ► CBC/DC: 06/14 WBC: 9500, Hb: 13.8, PLT: 290K, PTINR 1.0 ► ► Biochemistry: 06/14 BUN: 23.9, Cr: 0.85, Na: 140, K: 3.8 HbA1C: 6.9, TG: 111, LDL: 114, Cholesterol: 186 Uric acid: 6.3

11. Diagnosis ► Favor right hemisphere ischemic stroke

12. Hospital Course ► Admission on 12/23 ► Transcranial Doppler : 12/26  Normal flow in the posterior circulation ► CT of brain: 12/23  No gross ICH ► MRA of Head & Neck : 12/24   Acute infarcts at right MCA and PCA territory   Old infarct at right basal ganglion   High grade stenosis (>50%) at right proximal cervical ICA

13. Hospital Course ► Angiography 12/30  R't cervical bifucation: 57%  R't V1: 75%  L't P1: 70% ► Conservative treatment ► Join PAC program

14. Thank you!!! Thank you!!!