Case 05

Clinical history and examination

Age: 86 years, Male.
Time of presentation: 10:30

History of event

• Symptoms: unable to speak, right sided weakness
• Current time interval since last known well: 2 hrs 30 mins (150 mins)

Past medical history

• Previous ischaemic stroke with residual mild left sided weakness
• Recent non stemi MI

Relevant medications

• Aspirin and Clopidogrel
• Statin
• ACE I
• Diuretic

Relevant social history

• Living circumstance: at home with daughter
• Prior function and care needs: can walk in house, electric buggy out doors, can wash, dress but needs some help
• Work/hobbies: retired, watches racing on TV, enjoys grandchildren

Examination

• Pulse: 76, BP 205/85
• Neuro:
  • Handedness: right handed
  • NIHSS:  20
  • Deficits: severe aphasia, severe right face, arm and leg weakness, likely hemianopia

Investigations requested with non imaging results