Case 06

Clinical history and examination

Age: 36 years, Female.
Time of presentation: 14:00

History of event

• Symptoms: 2 days of right headache, pain in neck – sudden onset left sided weakness
• Current time interval since last known well: 1 hr (60 mins)

Past medical history

• Migraine with aura
• 4 days post normal vaginal delivery with epidural

Relevant medications

• None regular
• Sumatriptan as required

Relevant social history

• Living circumstance: at home with husband
• Prior function and care needs: independent
• Work/hobbies: on maternity leave from accountancy job, triathlons

Examination

• Pulse: 100 reg, BP 110/70
• Neuro:
  • Handedness: right handed
  • NIHSS:  14
  • Deficits: left facial droop, weakness of left arm and leg, left neglect

Investigations requested with non imaging results