Tuesday, September 15, 2009



33yo chinese man
Background problem:
1) Young HPT (diagnosed 6 years ago age 27-28 years old), last seen by medical team in July 2009 Carotid doppler done: Left ventricular dysfunction, left ventricular thrombus, left internal carotid artery occlusion- on warfarin

2) CVA with dense right side hemiplegia and global aphasia (admitted in medical in Oct 2008- had neurorehabilitation)

Patient was admitted there from 22nd October 2008 to 1st May 2009 :

Hx from brother:
Presentd with less responsive, noted by family members since 2days ago. Condition worsened as previously pt was ADL independent, eventhouigh had Rt sided hemiplegia + global aphasia- pt was still able to bath/ eating by himself. This morning noted that pt was drowsy + PU in bed
. Hence, the family members brought pt immediatly to ED. Family claimed no h/o trauma at home. Compliance to medications - but last night ? took medications (including warfarin) by himself- no eye witness on how much he took
No fitting seen
No vomiting
No SOB/chest pain
No abdominal pain
No other complaint

Opening eyes spontaneously, on + off obeying commands
GCS E4V1(global aphasia)M5-6
Pupils 3/5 sluggish

BP 160/82
HR 100
Spo2 99% on air

Lungs: clear
P/a: soft, nontender

Tone: Rt UL/ LL increased, Lt normal
Noted Rt sided body hemiplegic- 0/5, Lt UL/LL >3/5
Reflexes left sided briskBabinski: bilaterally downgoing

CT brain: Lt pareital acute SDH, maximum thickness 1.3cm x 4.4cm (AP), over 10cuts MLS of 1.6cm to the right, sulci & gyri not well differentiated- ? generalize edema Lt lateral ventricles compressed- pushed to the Rt, rt temporl horn opened BC partially efface Blood ix: FBC: WCC 8.4, Hb 14.3, Plt 243 RP: U 8.8/ Na 139/ K 3.7/ Cr 86 PT/APTT: 10.8/22.2 INR: 1.15 Impression: Lt parietal acute SDH ? 2' to overwarfarinization
He underwent craniectomy and evacuation of clots. Intra-op FFP was transfused. Post-op he was ventilated and sedated.Sedated on IV midamorphine 5mls/hr o/e:Pupils 2/3 sluggish BP 122/88HR 102AfebrileSpo2 99% on air Noted still slowly oozing head drain site Head drain 22cc

Repeated CT brain post op noted:Reaccumulation of bleeding.
He was subjected for another operation
Post-op, he was put on sedation and ventilation support. A repeat CT scan was performed.

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