Stroke Strike One

in our family.

The patient's angle differs greatly from the doctors.

The doctor is concerned with diagnosis and treatment, with what tests to do and ultimately with the prognosis. We make many mistaken assumption along the way, to be honest.

The patient and caregiver are more concerned about getting along day to day, and are involved with solving the minutiae of activities of daily living.

Stroke strike one member in our family, my Papa (father-in-law).

EXAM DATE/TIME: 14/08/2008 13:46 RADIOGRAPHER: NDILZX

RADIOLOGICAL REPORT CHEST. the heart size is normal. No active lung lesion detected.

CLINICAL HISTORY: new onset right sided weakness
hypertension,hyperlipid
VRE

MRI BRAIN: Multiplanar sequences of the brain were obtained. Comparison was made with the previous MRI of 17/8/2005 ( 3 years ago).
An acute small infarct is seen in the left anterior paracentral pons.
The previously noted acute infarct in the right lateral thalamus, involving the posterior limb and genu of the right internal capsule, new appears chronic.
The old right inferomedial cerebellar infarct is unchanged. An interval old small infarct has developed in the right frontal subcortical white matter.
The lenkoaraiosis changes present in both cerebral hemispheres appear more extensive.
No mass effect or hydrocephalus is seen.
Age-appropriate involutional changes are evident.
The included major intracranial vessels retain normal signal flow voids.
The visualised osseous structures, orbits and paranasal sinuses are unremarkable.

IMPRESSION: Acute small infarct seen in the left abterior paracentral pons.
AUGUST 14 2008 08:58 NDIYIB

PHYSIOTHERAPHY
Balance:
static sitting (poor)
dynamic sitting (poor)
static standing (poor)
dynamic standing (poor)
Activity tolerance (fair)
Rehab potential (fair)
Date :13/8/08 Time: 12:46

NUH HOSPITAL INPATIENT DISCHARGE

1. PATIENT IS DISCHARGED WITH 2 DAYS OF SC FRAXIPARINE

2.MEDICAL SERVICE CODE :STK - NEUROLOGY - STROKE

3.CLINICAL DIAGNOSIS: Principal Diagnosis : LEFT PONTINE STROKE

4.DISCHARGE MEDICATION:
DRUG NAME AND FORM -( DOSE AND FREQUENCY) - DURATION/QUANTITY
1.SIMVASTATIN TABLET(20MG EVERY NIGHT)2WEEKS

2.PLAVIX TABLET (75MG EVERY MORNING)2WEEKS

3.METFORMIN TABLET (850MG EVERY MORNING)2WEEKS

4.LOSARTAN TABLET (25MG EVERY MORNING) 2WEEKS

5.FRAXIPARINE INJECTION (0.3ML EVERY MORNING) 2DAYS

CLINICALSUMMARY
72/Chinese/Male
premorbidly ADL independent, community ambulant, lives in Malaysia;visiting daughters&sons in S'pore.

Past medical history:
1.DM
2.HTN
3.CVA 2005 in Malaysia
- R-sided weakness
- came to S'pore for further care
- full functional recovery
- MRI brain 2005 L thalamic infarct
- started on Aspirin

C/O
1. sudden onset right UL & ll weakness 2/52 ago in S'pore (visiting sons & daughters)
- a/w R facial droop, slurring of speech
- no visual disturbance or headache
- no chest pain, SOB
- family not certain if patient is compliant with meds

O/E:
Alert, Oriented
Vitals: afebrile, BP 194/100, PR 80
H: S1S2
L: clear
Abdo soft and tender
CNS:
GCS 15
PEARL
R facial droop
slurred speech
power
- Right UL / LL 2/2
- Left UL / LL 5/5
reflexes normal ; plantars down going

INVESTIGATIONS
TG 0.9 LDL 3.95
H6A1C5.8%

Issues:
1. L pontine infarct
- CT brain : Suspicion of an acute left paracentral pontine infarct
- MRI brain : Acute small infarct seen in the left anterior paracentral pons; An interval old small infarct has developed in the right frontal subcortical white matter. Chronic infarct in the right lateral thalamus, involving the posterior limb and genu of the right internal capsule.
- US carotids : No hemodynamically significant stenosis of the major extracranial arteries.
-TCD : Stenosis of the M2 segment of the right MCA. Stenosis of the M1 segment of the left MCA (bilateral MCA stenosis).
- aspirin changed to plavix since patient developed stroke while on aspirin
- underwent physiotherapy inpatient
2 - Hyperlipidemia
- started on statins (cholesterol-lowering drug)

DISCHARGE : IMPROVED

$$$$$NUH HOSPITAL SINGAPORE$$$$$$$$$$
STATEMENT OF CHARGES AS AT 20.08.2008

CASE NO: 1580456843J
ADMISSION : 12.08.2008 17:51 (DISCHARGE : 19.08.2008 13:00)
WARD CLASS : CLASS B1 (4 BEDDER)
PATIENT STATUS: NON-RESIDENT

SERVICES
Room Charge Class B1 (8 day(s) @ $199.02)-=$1,592.16
Daily Treatment Fee Class B1 (8day(s)@78.11 =$624.88
Consumables (???) = $35.31

INVESTIGATIONS
Laboratory = $460.00
Magnetic Resonance Imaging (MRI) = $749.00
Specialised =$503.98
X-ray =$369.15

MEDICATIONS
Non Standard =$176.95
Standard =$71.36

THERAPY SERVICES
Assessment & Counselling =$58.85
Ward/Clinic/Other Procedures =$1,198.40

TOTAL CHARGES = $6,434.39
A&E Amount Transferred = $90.00

TOTAL AMOUNT PAYABLE = $6,524.39

Bill amount = $6234.74
Estimated deductible from Medisave Account(youngest son's)=$3,600.00-
Payment (admission deposit) =$1,600.00

Out-standing to-date = $1,034.74
Please top up deposit of = $3,040.00

(figures were copied from Singapore National University Hospital official receipt)