RESUMO
An 89-year-old woman was admitted with a fall. She had severe dementia and was on no medication. She was mobile with carers visiting her at home twice daily. While her stay in the hospital, she was diagnosed with atrial fibrillation. Her rate was controlled with bisoprolol and was already given aspirin after risk assessment for stroke and CT scan of head. Several days into admission, she complained of sudden onset of weakness of her right upper limb with pain. On examination, there were absent brachial and radial pulses on the side along with weakness and decreased sensation below right elbow. She underwent urgent CT angiogram which revealed absent flow beyond right subclavian artery. She was treated with heparin infusion and then warfarin with regular vascular team follow-up. Further issues such as duration of warfarin therapy including possible substitution with direct thrombin inhibitor such as dabigatran etexilate is under consideration.