CASE 2

Mr PBH a 66 years old Chinese gentleman with history of hypertension for 2 years, not under regular follow up and medication presented  with right upper limb weakness that occurred spontaneously at 6pm on the day of admission (10/3/2013). There was associated headache over the left temporal region the whole day before the weakness occurs. There was dizziness as well. Patients adds that he was working under the sun the whole day and was not feeling very comfortable. However there were no LOC, fits, chest pain, shortness of breathe. No other significant history in systems review, family and social history.

Physical examination revealed an admission BP of 220/120mmHg. He was then given 10mg Amlodipine stat dose at the ED before transferred in to our care at ward 3. Pulse was 90bpm, with normal breathe rate of 20 and afebrile.  GCS was full and he was alert conscious and communicative. CNS examination revealed right sided hypotonia , areflexia and 4/5 power over the distal joints of the upper limb. No findings over the lower limb, CN 2,3,4,6,7,9,10. CVS, Respi and abdomen examination was normal.

Investigation (FBC, ECG, RP, LFT, Chest Radiograph, coagulation profile, FSL, RBG) was taken.  A CT BRAIN was scheduled to rule out haemorrhagic CVA.

A provisional diagnosis of ischemic CVA secondary to hypertensive emergency was made.

The management was tailored to lower his BP. He was given captropril t12.5mg stat dose. He was then on maintenance dose of perindropri 4mg OD and Amlodipine 10mg OD.

Patient progress Day 1 admission. 

- BP went down to 170/110mmHg after initiation of anti hypertensive. He was allowed orally. He was sent for a CT brain in the morning.

- all investigations was traced and was normal except for an increased CK and LDH.

- RP showed urea and creatinine of 3.8 mmmo/l and 94 mmmol/l and we decided to start him on ACEi

- FSL had a normal total cholesterol level however with elevated TG (2.1mmol/l)and low HDL (1.2mmol/l)

Patient Progress day 2 of admission

- BP is still maintained around 170/100mmHg

- CT Brain reveled no haemorrhagic nor ischemic areas.

- He was then referred to the OPD for follow up on his hypertension.

- he was educated about his disease  of CVA, HYPERTENSION, dyslipidemia and possible complication of his disease process.

- He was then discharged with Perindopril 2mg OD, Amlodipine 10mg OD, lovastatin 20mg ON, aspirin 150mg OD.

- he was given a referral to the KK to repeat the RP and monitor the BP and for care his hypertension and dyslipidemia.