Case 12

Clinical history and examination

Age: 84 years, Female.
Time of presentation: 12 noon

History of event

• Symptoms: fell, fractured right ankle, found to have right sided weakness
• Current time interval since last known well: 2 hrs 45 mins (165 mins)

Past medical history

• Osteo arthritis
• COPD

Relevant medications

• Inhalers
• Analgesics

Relevant social history

• Living circumstance: home alone
• Prior function and care needs: independent, walks with stick outside
• Work/hobbies: retired, knitting, volunteer in cafe

Examination

• Pulse: 70, BP: 166/88
• Neuro:
  • Handedness: right handed
  • NIHSS: 8
  • Deficits: right facial droop, moderate weakness right arm and leg, no hand function, sensory loss on right

Investigations requested with non imaging results