Chronological Timeline of Patient's Active Issues
Initial Presentation (Day 1)
- Emergency Department presentation with acute neurological symptoms: aphasia, decreased level of consciousness, and right lower limb weakness 1
- Initial imaging in Hafer Al-Batin: CT scan identified middle cerebral artery (MCA) territory involvement 2
- Stroke onset: Approximately 2 weeks prior to current admission (subacute phase) 1
Diagnostic Confirmation (Day 1-2)
- Brain MRI findings: Subacute infarct in the left parietal periventricular area, with stable imaging compared to prior studies 1
- Stroke classification: Subacute stroke (two weeks since symptom onset) confirmed by neurology consultation 1
- Multiple old strokes identified: Patient had been on dual antiplatelet therapy (DAPT) prior to this event, raising concern for cardioembolic mechanism 1
Complication #1: Pulmonary Embolism (Day 2-3)
- PE diagnosis: Most likely provoked by prolonged immobilization for 14 days following the recent stroke 1
- Risk factors: Immobilization is a well-established risk factor for venous thromboembolism in stroke patients 1
- Anticoagulation decision: Neurology confirmed mild bleeding risk and explained hemorrhagic transformation risk to family; family agreed to anticoagulation after risk-benefit discussion 1
- Cardiology consultation: Recommended holding antiplatelet agents until cardiology evaluation to avoid triple therapy complications 1
- Hematology referral: Planned for anticoagulation choice optimization 1
Complication #2: Urinary Tract Infection (Day 3-4)
- UTI diagnosis: Hospital-acquired infection versus dehydration-related 1
- Urinalysis: Suggestive of active infection 1
- Urine culture results: 100,000 CFU/mL Escherichia coli, susceptible to Trimethoprim/Sulfa, Nitrofurantoin, Gentamicin, and Ceftriaxone 1
- Treatment: Ciprofloxacin initiated, currently Day 6 of therapy 1
- Context: UTIs occur in 15-60% of stroke patients and independently predict poor outcomes 1
Complication #3: Transaminitis (Day 4-5)
- Initial AST elevation: 235 U/L 3
- Suspected etiologies: Drug-induced (statin held) versus viral hepatitis 3
- SARS-CoV-2 detected: Positive test suggests viral contribution to liver injury 3
- Improving trend: AST decreased to 50 U/L, indicating resolution 3
- Abdominal ultrasound findings: Intra- and extrahepatic biliary ductal dilatation identified, potentially contributing to transaminitis 3
Ongoing Workup and Management Plan
Comprehensive stroke workup recommended by neurology 1:
- Echocardiography to evaluate for cardioembolic source
- Prolonged cardiac monitoring (given multiple old strokes on DAPT suggesting possible paroxysmal atrial fibrillation)
- Malignancy screening (multiple strokes despite antiplatelet therapy raises concern for hypercoagulable state or occult malignancy) 1
Anticoagulation strategy: Transition from DAPT to anticoagulation once cardiology approves, with close monitoring for hemorrhagic transformation 1
Infection management: Complete antibiotic course for UTI; monitor for hospital-acquired pneumonia given immobilization and dysphagia risk 1
Rehabilitation needs: Early mobilization critical to prevent further complications including additional VTE, pneumonia, and pressure injuries 1