Case 04

Clinical history and examination

Age: 64 years, Female.
Time of presentation: 19:00

History of event

• Symptoms: husband witnessed stopped speaking, right face, arm and leg weak
• Current time interval since last known well: 1 hr 30 mins (90 mins)

Past medical history

• Diabetes mellitus
• Proliferative retinopathy
• Ischaemic stroke 3 yrs ago
• End stage renal failure
• 3 x weekly haemodialysis (last completed 48 hrs ago)

Relevant medications

• Insulin: not taken today
• Aspirin

Relevant social history

• Living circumstance: at home with husband
• Prior function and care needs: independent in everyday activities
• Work/hobbies: retired shop assistant due to ill health, grandchildren, crosswords

Examination

• Pulse: 82, BP 174/75
• Neuro:
  • Handedness: right handed
  • NIHSS:  12
  • Deficits: mod aphasia, right UMN facial weakness, some effort against gravity in arm and leg but no hand movement

Investigations requested with non imaging results

• BM 23mmol/l
• Hb 80g/dl
• Urea 22mmol/l
• Creat 300umol/l