Patient Name: Md Rodzi bin Ismail, 55 years, Male Underlying: DM ( not compliant to Jardiance and Diamicron , Dyslipidemia, Ischemic dilated cardiomyopathy 30/5/2026 2 pm Wide found patient lying unconscious in room, giddiness and fell down around 2.05 pm, left side body weakness. Went to KMC and performed plain CT brain and got results aroyund 4.38 pm indicatrinf suggestive of acute right MCA infact, right frontal encephalomalacia and gliosis and pansinusitis. At 5.40 pm, T. Co Plavix 1/1 STAT , T. Lipitor 40 mg STAT given GCS full, pupil reactive, , left facial asymmetry, slurring of speech, power left: ⅕, right 5/5, ECG: SR, sensation intact, DXT: 154, BP: 144/181, HR: 87 Went to Hospital Sultanah Bahiyah (HSB) ED at 7 pm GSC: E3V4 (Slurred) M6 Tachypneic, obey simple command, + right eye dropping, + left facial asymmetry, SPO2 under RA: 80%, under FMO2 5L/min is 89% and 97% under HFM, Lungs: crepitations over Left side, CVS: DRNM, PA: soft, non tender Reviewed in ward 31/5 O/E: GCS: E3V1M6, DXT: 13, Lungs: bibasal creps, BP: 115/69, PR: 110, T: 37, SPO2: 96% under FMO2, no pedal edama, no gag reflex, moving right upper and lower limb, unable to fully assess neuro, ? delirium Impression: Acute right MCA infarct with left hemiparesis and aphasia NIHSS 12, aspiration pneumonia, decompensated heart failure with underlying dilated cardiomyopathy Iv pantoprazole OD 31/5 8 am S/C actrapd 10 U STAT 2.25 am Plan: Off IV drip Insert RT and start RT 50 cc/ 3 hourly Continue IV augmentin DXt QID T aspirin 150 mg OD T atorva 40 mg ON S/C Actrapid 6U PRN if DXT >12 IV Lasix 20 mg STAT and BD (KIV off cm) Syrup lansoprazole 30 mg BD Wean under NPO2 cm 1/6/2026 Under HFM BP: 116/ 65 Not tachypneic PR: 115 T: 37 SPO2: 97% E3, V1, M6 Lungs: Bibasal creps DXT: 12 Plan: Continue RTF 100 cc/3 hourly IV Augmentin Trace culture DXT QID S/C Actrapid 6U PRN if DXT >12 I/O chart Continue IV lasix Wean down to NpO2 (> 95%0 CT brain if GSC drop ECHO inpatient CT angio 2/6/2026 9.10 am O/E: E4V1M6 Left sided: 0/5 Lungs clear CXR: pneumonia patches No AF, ECG: SR Plan: Repeat CT brain Trial off HPO2 SC insulatard 10 U STAT and BD RTF 150 cc 3 H, 200 cc x 3, then 250 cc x 2 Continue augmentin Start t metformin 500 mg BD STAT and BD 2/6/2026 4.35 pm The repeated CT brain shows small punctuate with mass effect Plan: IV mannitol 200 mg STAT and 100 mg TDS 2) WH aspirin Stated that it can cause cardiorespiratory arrest which requires intubation with 3 expected outcomes: which is best outcome, worsening condition, or prolonged ventilation and need for tracheot?? (unable to read) May also develop cardiac arrest and need for CPR indication . Faimly are indecisive . waiting for another members input 2/6/2026 8.45 pm Patient desat from NPO2 SPO2 -> 88-89% now requiring HFMO2 Upon review HFMO2: O/E: E4V1M5, pupils reacted, BP: 120/76, PR: 146, T: 37, SPO2: 98 %, DXT : 17 (repeated 23.1 ?? Unreadable) , ketone 1.6 Lung transmitted sound Plan: Refer neurological for massive cerebral infarc with hemorrhagic (KIC craniectomy) Awaiting for family decision W/H RT feeding and to NSM? W/H metofrmin and S/c insulin Start S?C insulin sliding scale 6 IV drip 30 NS/24 H IV drip 10 NS/ 4 H DXT 4 hourly Insert new branula Right decompressive craniectomy 2/6/2026 11.30 pm After discussing with family regarding the option of right decompressive craniectomy, family not keen for surgery, cpr, intubation, only wants best medical therapy Plan: Best medical therapy T Neurosurgical input Continue HFMO2 , keep SPO2> 95% Continue IV drip Continue NBM with DXTH? And insulin sliding scale KIV morphine if patient restless and tachypneic 3/6/2026 9.20 am Currently: desaturated yesterday on HFMO2, family input noted, keen for conservative management O/e: pupil equal but not reactive , 2 mm BP: 121/77 PR; 127 T: 37 SPO2: 99% DXT: 6.7 Lungs: clear anteriorly Plan: S/c insulatard 10 U STAT, then BD< Off insulin sliding scale Resume RTF IV mannitol 100 mg TDS for one day then stop STart RTF 200 cc/ 3 H Off IV drip Off cardiac monitor In event of desaturation, not for inotrope, intubation or cpr ECHO inpatient as planned Restart aspirin 4/6 2026 9.20 am Issue: Right MCA infarct with midline shift mass effect (conservative ma nagement) Aspiration pneumonia Uncontrolleld DM AKI? ARI? Currently, Afebrile, no destauration under HFMO2 Following RTF 200 cc/3 hourly O/E: E3, V1, M5 , moving R side of body BP: 133/85 T: 37 SpO2: 100% under HFMO2 DXT:11.8 Explained to caregiver regarding current condition having huge stroke causing mass effect. The likelihood of vegetative state is high. Patient caregiver keen to bring to aurlius hopital but already explained that [atient is already on day 5 of stroke and the management will most likely be the same. Also negated regarding the neurological input, understood they will contact the aurelius hospital first Plan: 1)Trial of VMo2 60% 2) Increase insulatart to 14 U BD 3) Increase RTF to 250 cc/ 3 hourly 4) DXT QID 5) awaiting family decision regarding transfer to aurelius hospital 6) for inpatient echo (TRO LV thrombus) 7) continue IV augmentin 1/52 8) off iv manitol (completed) This is my patient case that needs to be presented . The flow of presentatin should be[05/06, 17:28] anuu♥️: Flow of presentation: 1. Patient, age, gender 2. ⁠what is the chief complaint 3. ⁠what is the diagnosis 4. ⁠on day 1 admitted, wht problem then give what medication, indication for what, then is it appropriate to give the med for this problem, any more better option? (No pci then skip nxt day- same flow summary - until the last day) 5. ⁠next day, some symptoms resolve, dr stop certain medication due to …. Then some other problem arise and dr prescribe ….. the indication for the medication is for …… is it appropriate….. 6. ⁠overall no PCI in this case / u found some pci and need some clarification….. 7. ⁠thank you [05/06, 17:28] anuu♥️: Yes, but rather than solely mentioning if the medications are appropriate or not, it would be better to state indications. For eg, this pt was started on Tab pantoprazole 40mg BD for (indication) from (duration). Then if anything was found inappropriate/incorrect, it can be mentioned as a PCI & then explain accordingly [05/06, 17:28] anuu♥️: Your flow is correct. Just follow the CP2 sections ..I'll attach the cp2 form too..pls help me fill in that accurately . This case is abit complicated to me pls help me