Case #4: Sudden right-sided weakness

An 81/F is brought in by her family for sudden weakness of the right side of the limbs and body
and inability to speak.
2 days PTA, the family narrated that she had an episode of confused speech with a feeling of a
numbness of the right side. This resolved after a few minutes but recurred again twice the day
before. One episode was associated with transient blindness of the left eye lasting about 5 to
10 minutes. The woman attributed it to fatigue from house cleaning and refused to go to the
hospital.
About 4 hours PTA, the patient was sweeping her backyard when she suddenly fell down and
was unable to get up. The family noted that she was barely talking but mostly nonsense, and
that she didn’t move her right side. They decided to bring her to the hospital.
She has a history of hypertension for about 25 years, usual BP is 140/80 on losartan/amlodipine
50mg/5mg once a day. She also has a history of hypercholesterolemia for more than 20 years,
for which she takes rosuvastatin 10mg once a day. Last cholesterol level was 260 mg/dL, taken
two months before. She is poorly compliant with her medication.
She doesn’t smoke or drink alcohol. She doesn’t exercise but takes long walks for about 30
minutes a day.
General Survey: Awake and looks at examiner but doesn’t talk. She is slightly overweight
(estimated BMI ~ 28)
Vital Signs: BP: 180/90; HR: 98 (1 min); RR: 16/min; T°: 36.8 °C; O2 sat: 96%
Head: normal head configuration, no tenderness
Eyes: no periorbital swelling or redness; symmetrical palpebral fissures; clear, white sclerae,
pupils 2mm ERRL, clear lenses, fundoscopy: (+) ROR, A:V ratio: 1:4, (+) few soft
exudates, (+) Hollenhorst spots in the left eye
Neck: neck veins are not dilated; (+) loud carotid bruit on the right
Chest/ Lungs: normal chest dimensions, symmetrical chest expansion, good air entry, clear
breath sounds
Cardiac: adynamic precordium, AB/ PMI: 5ICS, 2 cm lateral to the LMCL; distinct heart sounds:
S1>S2 at apex, S2>S1 at the base; regular heart rhythm; no gallops, no murmurs
Abdomen: full, normoactive bowel sounds, no masses, no tenderness
Musculoskeletal exam: Normal muscle bulk all limbs, no apparent limitations to passive ROM
Neurological examination:
MSE: alert, looks around the room and to the examiner but doesn’t talk or follow verbal
commands but can mimic the examiner’s movements
Cranial nerves: CN I: not tested;
CN II: good visual acuity, no visual field cuts;
CN III, IV, VI: pupils 3mm equal, briskly reactive; eye movements intact;
CN V: decreased right facial sensation; no weakness of the muscles of
mastication
 CN VII: severe right facial weakness but not including the forehead;
CNVIII: hearing seems to be grossly intact;
CN IX & X: poor palatal elevation on the right;
CN XI: poor head turning to the left;
CN XII: tongue midline
Motor: no abnormal involuntary movements; normal muscle bulk; slightly flaccid right
muscle tone; 1/5 to 0/5 weakness of the right-side limbs
Sensory: decreased response to noxious stimuli on the right side of the trunk and limbs
DTRs: +3 hyperreflexia of the biceps, triceps, brachioradialis, knee jerks, ankle jerks on
the right side; positive Babinski sign on the right
Cerebellar: FTNT could not be assessed as she doesn’t follow commands; no nystagmus
Meningeal: no Brudzinski sign; normal straight knee leg raising test

Questions for discussion:

1. What is the first thing to do as soon as the patient enters the emergency room?
2. Localize the lesion. Describe the location of the stroke and the basis for why you think it is
there.
3. What would be the main consideration (diagnosis), including the etiology or cause of the
stroke? Give the reasons to support this diagnosis.
4. What are the differential diagnoses for other causes of the stroke? Give at least 3 and the
reasons to support each differential diagnosis, and the reasons why it is possible to rule
each one out.
5. What would be the best neuroimaging test to do at this time? Why? What are its
advantages over the other neuroimaging tests.
6. What other lab tests would you need? Enumerate the reason for each lab test.
7. What initial medications would you want to give for the stroke? Give the reasons for each
medication. Is this patient a candidate for thrombolysis?
8. What would be the best medication needed to prevent another stroke for this patient?
How is it given? Justify your choice.
9. Did the patient need medication to prevent strokes prior to his event? Which medications
and give the reason why?
10. What other medication would you give this patient for her co-morbid conditions? Give the
dosages and the reasons why she needs them.