Case presentation in internal medication examination. See description.

1. 內科專科口試 107年度
姜冠宇 醫師

2. 題號 性別、年齡 主 述 診 斷 CASE有圖片，請打勾(V) 是本人照顧，請打勾(V)
CASE 1. 55 y/o Male ; Acute onset of left side weakness (V) ( )
1. Permanent atrial fibrillation s/p left atrial appendage occluder implantation
2. Recurrent embolic stroke at right middle cerebral artery territory, s/p Intravenous tissue
plasminogen activator, s/p Intra-arterial thrombectomy, with good neurologic recovery
CASE 2. 44 y/o Male ; Suddenly onset abdominal pain (V) (V)
Acute pancreatitis with acute respiratory failure
CASE 3. 44 y/o male ; Progress shortness of breath for 1 week (V) (V)
1. Pulmonary tuberculosis with cavitation
2. Acute respiratory distress syndrome
CASE 4. 66 y/o female ; general weakness for 5 days (V) (V)
1. Acute kidney injury on chronic kidney Disease
2. Hyponatremia
CASE 5. 56 y/o female ; Fever up to 40’C with chills for 1 day (V) ( )
Infective endocarditis of mitral valve, Staphylococcus aureus(MRSA)
CASE 6. 54 y/o female ; Intermittent vomiting and diarrhea for 2 months (V) (V)
Lupus enteritis

3. Case 1
53-year-old-man with acute onset left side weakness on 2016/09/06

4. CASE 1. 病例摘要
主訴：
53-year-old-man with acute onset left side weakness on 2016/09/06
簡單病史：
History of (1) Af (2) Old CVA (3) Hypertension, F/u at other CV Department under Pradaxa (110) 1# BID.
He had acute onset of left side weakness found by his colleagues at 14:00, 2016/09/06. He was then sent
to our ER immediately at 14:40, with initial BP 135/92 mmHg and GCS E4M5V6. Head CT did not reveal
ICH. The neurologist was consulted and NE showed no aphasia, mild dysarthria, left central facial palsy,
and eyeball deviating to the right side. The NIHSS scored was around 15-16. After discussing with the
patient and family, they could understand the indication and possible complication of IV tPA. IV tPA 40mg
(loading 4mg, then slowing infusion 36 for 1 hour) was given at 15:33. NIHSS did not improve (still 15-16)
when iv r-tPA finished. IA thrombectomy has been done then. After IA thrombectomy, Fulling
recanalization of the right M1 MCA was seen in angiography. The NIHSS dec. from 15-16 to 6.
The risk factors survey including biochemistry test, ECG, duplex, and MRI of the brain were checked. The
cardo echo checked on 2016/09/14 was reported as LAA thrombus from precordial views (1.1x1.7cm)
Dilated LA & LV, Poor LV contractility, LVEF 30% Probable LV diastolic dysfunction, LV symmetrical
hypertrophy. The consulted cardiologist has suggested Pradaxa (150) 1# BID. Due to the recurrent stroke
and AF, he was admitted to LA occluder since LVEF improved; LAA thrombus dissolved.

5. 55 y/o Male with acute onset left side weakness
Acute onset of left side weakness on 2016/09/06 14:00
Slurred speech, Left facial palsy, Left side numbness
● Hypertension
● Old CVA
● Gout
● Hypothyroidism
● Dilated cardiomyopathy
● Atrial fibrillation for 15+ years
○ CHA₂DS₂-VASc score 4
● Stroke 5 months ago
History
P.I.

6. Physical examination
General
Appearance
Development: Normal
Cooperation: Yes
GCS E3M6V5
BP SBP 110 / DBP 71mmHg
HR 130 /min
RR 21 /min
BT 37.8 ℃
Conjunctiva: pink
Sclera: anicteric
Pupil: 3.5+ / 3.5+
Head & Neck
Thorax
Thyroid: No goiter
Lymphadenopathy (-)
Chest wall: equal chest expansion
Lung: clear,no rhonchi or wheezing
Heart: regular heart beats, no murmurs
Abdomen
Tenderness: No muscle guarding
Palpable Mass: nil
Kidney: no flank pain
Bowel Sounds: normoactive
Extremities: no pitting edemaOthers

7. Neuro Examination
❏ Conscious Drowsy +1
❏ Partial deviation to R’t +1
❏ Complete hemianopsia +2
❏ Minor facial palsy +1
❏ Motor Arm no movement +4
❏ Motor Leg no movement +3
❏ Sensory partial loss +1
❏ Dysarthria +1
❏ General complete hemineglect +2
16

8. Lab data
Na 140 mmol/L
K 4.1 mmol/L
Cr 0.99 mg/dL
ALT 24 IU/L
HGB 15.6 g/dL
PLT 192 10 3/μL
PT 12.1 sec
APTT 27.4 sec
WBC 7.81 10 3/μL
Neu 45.0 %
Lym 46.1 %
Mono 5.5 %
Eosin 3.1 %
Baso 0.3 %

10. CXR

11. Brain CT

12. Following up CTA

13. IA thrombectomy

14. Supportive care and f/u
Monitor neruolgical sign
17:03
19:50 Significant Neurological improvement
Muscle power of arm : R't 5/ L’t 4
Muscle power of Leg : R't 5/ L’t 4
ICU
20:30
16:35 No significant change after IV tPA
NIHSS Total Score: 15 → 4
IA thrombectomy → Sucessful Recanalization

15. Survey the Etiology of Recurrent Stroke
Bioche
Result
No dyslipidemia
Normal thryoid function
Duplex Carotid ultrasound:
No carotid stenosis
24 hr
holter
No need (chronic Af)
TSH 0.110 uIU/mL Cholesterol 148
free T4 1.53 ng/dL TG 69
TSH receptor Ab < 3.00% LDL 85

16. CV Echo

17. summary of clincial course
Post CVA care
Hydration 1000cc QD + Aspirin 1# QD
Monitor nerological sign + Rehabitation
9/10
Ward
9/6
ER
ICU
MCA infarct s/p IA thrombectomy
Survey etiology
LAA thrombus
9/21
Neuro OPD: Near total recovery
CV OPD follow up for LAA thrombus
Pradaxa 150mg/cap 1.000 粒
BID
Capoten 25mg/tab 0.250 粒
BID
Aldactone A 25mg 0.500 粒
QD
NIHSS Total Score: 16 → 4
9/17
MBD
NIHSS Total Score: 0
Barthel Index：10 → 85
Modified Rankin Scale：5 → 3

18. Keep dabigatran，Follow up TEEOPD
10/27
01/11

19. Final diagnosis
1. Recurrent embolic stroke at right middle cerebral artery territory,
s/p Intravenous tissue plasminogen activator, s/p Intra-arterial
thrombectomy on 2016/9/6, with good neurologic recovery
2. Permanent atrial fibrillation s/p left atrial appendage occluder
implantation
3. Congestive heart failure, EF 30%, dilated cardiomyopathy related
4. Hypertension
5. Hypothyroidism, under eltroxin