Case 3 - Cerebrovascular Accident with Right Sided Hemiparesis secondary to Hypertensive Emergency

Mr SJ, a 60 years old Malay male with a history of diabetes and hypertension for past 1 year presented with right sided hemiparesis that occurred upon awakening on day of admission. There was associated headache, dizziness and blurring of vision that came along with the presenting symptom. He also complained of having palpitations. However, he did not complain of any chest pain, sweating, or shortness of breath. He also has no slurring of speech or swallowing problems and is currently unable to walk due to right lower limb weakness.

Physical examination revealed on admission BP of 220/114 mm Hg. He was then given IV Labetalol 10 mg stat dose. Pulse was 79 bpm, with normal breath rate of 20 and was afebrile. GCS was full and he was alert, conscious and communicative. CNS examination revealed right sided normotonia, brisk reflexes and power 1/5 power over right upper limb, and power 2/5 over right lower lib. Cranial nerves and sensory were intact. CVS, respi, and abdomen examination were normal.

Investigation (FBS/FSL, RP, LFT, Ca, Mg, PO4 and coagulation profile was taken). A CT brain was taken and revealed no ischaemic changes.

A provisional diagnosis of: Cerebrovascular Accident with Right Sided Hemiparesis secondary to Hypertensive Emergency was made.

The management was to monitor vital signs 4 hourly and to allow orally since he did not have any swallowing impairment. He was given aspirin 300 mg stat and 150 mg OD, simvastatin 40 mg ON, subcutaneous actrapid 6 unit in view of blood glucose on admission was 17.6 mmol/L. He was also referred to a physiotherapist to regain functionality and muscle strength.

Day 2 of admission

Blood pressure was still high with 180/110 mm Hg. He was then started on tablet perindopril 4 mg OD. His muscle power has slightly been improved with 2/5 on right upper limb and 3/5 over right lower limb. There was still continued follow up with the physiotherapist.

 

Day 3 of admission

Blood pressure still maintained at 174/94 mm Hg. However, his power over the right upper limb has improved to 3/5 and right lower limb still maintained at 3/5. His blood parameters were within normal range. His TG and LDL were elevated with 2.1 and 5.4 respectively. His potassium was low at 2.4 and after fast correct with 1.5 g KCl, his potassium level improved to 3.5.

 

He was then discharged with tablet aspirin 150 mg OD, perindopril 4 mg OD, metformin 500 mg BD, gliclazide 40 mg BD, and tablet simvastatin 40 mg ON. A memo was written  to Klinik Kesihatan to continue monitoring the blood pressure and to come again with a repeated renal profile and fasting serum lipid, in view of his dyslipidaemia and hyperkalaemia. He was also given slow K for the next 3 days.