CLINICAL CASE

Presenting complaints
Left-sided body weakness for 8 hours prior to admission.

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History of Present Complaints:
Ms. A, a 75-year-old lady with underlying type 2 diabetes mellitus, hypertension, and
dyslipidaemia, came in presented with sudden onset of left-sided body weakness for 8 hours
associated with slurred speech and facial asymmetry. The weakness was continuous throughout
the whole duration prior to admission, initially manifested as subtle weakness, and had slowly
progressed to mild weakness accompanied with numbness over the patient’s left face, upper and
lower limbs. Upper part of face was spared from numbness sensation. Ms. A also experienced
drooling of saliva and slurred speech, and was told to have drooping of left face by her family
members. The precipitating factor was unknown.
Ms. A denied of paraesthesia, complete loss of sensation, reduced or loss of vision, inability
to speak or understand conversation at all. There was no pain, headache, nausea, vomiting, neck
stiffness, fever, dizziness, difficulty in swallowing, urinary or bowel incontinence, nor had she
experienced loss of consciousness or fitting episodes. Ms. A also denied of cerebellar symptoms
such as vertigo, double vision, poor muscle coordination, tremors, or uncoordinated walk with
wide gait.
This is Ms. A’s first time to experience such symptoms. Mr. A did not have history of
epilepsy, head trauma or fall, nor it has any association with her oral hypoglycaemic agent intake
or abuse of recreational drugs. Ms. A was not on insulin. Ms. A also did not have history of
cardiovascular diseases, nor she had cardiovascular-related symptoms including chest pain,
palpitation or shortness of breath on exertion.
Ms. A is right hand dominant.

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Systematic Enquiry/Review:
 Systems Findings

General review No fever, loss of appetite, weight changes, sleeping difficulties,

lethargy, night sweat

Cardiovascular system No chest pain, palpitation, shortness of breath on exertion,

claudication. No signs of fluid overload (oedema, orthopnoea,
paroxysmal nocturnal dyspnoea. No syncope

Respiratory system No shortness of breath, coughing, sore throat, stuffed or runny nose,
sputum production, wheeze, or haemoptysis.

Ear, nose, throat No ear pain, tinnitus, nose bleed, snoring, loss of smell nor loss of
taste.

Central Nervous system As mentioned in HPI

Gastrointestinal system No heartburn, dysphagia, hematemesis, altered bowel habits nor

bowel incontinence. Normal stool colour

Genitourinary system No change in urine output, dysuria, nocturia, haematuria, hesitancy,

poor streaming, terminal dribbling, or urinary incontinence.

Musculoskeletal system No bone pain, joint pain, joint stiffness nor history of falls.

Endocrine system No polyphagia, polydipsia, or dry skin.

Others No bleeding from any areas of mucosa, rashes or bruising noted at any
areas.

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Past Medical History
Diabetes mellitus
Ms. A was diagnosed with type 2 diabetes mellitus 20 years ago during one of her routine medical
check-ups. She was prescribed with oral hypoglycaemic agent of unknown name and dose, taken
twice per day. She had good blood sugar control with her last fasting blood glucose around 4.5 –
5 mmol/L, and HbA1c reading at 5%, taken on last follow up 2 months ago. She did not have
symptoms of hyperglycaemia such as polyphagia, polydipsia and polyuria. Ms. A also denied of
microvascular complications like blurry vision, paraesthesia of glove-and-stocking pattern, frothy
urine, or history of macrovascular complications.

Hypertension and dyslipidaemia

Ms. A was diagnosed with hypertension and dyslipidaemia at approximately 20 years ago as well.
She was prescribed with 2 types of antihypertensive medication, and 1 type of cholesterol-lowering
drug. She denied of headache, dizziness, or blurry vision.

Otherwise, Ms. A denied of other chronic diseases or malignancy, history of hospitalisation or

surgery. Ms. A also did not have history of varicella-zoster infection or taken VZV vaccine.

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Drug History:
Other than the medication mentioned above, she did not take any other medication, alternative
medication or additional supplement. She had no known food or drug allergy.

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Family History:
Ms. A is married with 7 children. She has 5 siblings, with her being the 3rd child. Her father had
passed away at his 50s due to stroke, while her mother had passed away at elderly age due to
unknown cause. Her elder siblings had type 2 diabetes mellitus, hypertension, and dyslipidaemia
as well. There was no family history of other chronic disease or malignancy.

Social History (SH):

Ms. A did not smoke or drink alcohol. She was compliant on low sugar and low salt diet restriction.

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On Examination:

Vital signs (ED)

Pulse rate : 66 bpm
Respiratory rate : 22
Blood pressure : 187/92 mmHg
Temperature : 37.2°C (afebrile)
SpO2 : 98 % under room air

General examination (in ward)

On inspection, the patient was alert, conscious and well-oriented with full GCS score.
There was a branula attached to the right dorsum. She was sitting comfortably in an upright
position with no signs of pain or respiratory distress.
On examination of the hands, the hands were pink and warm. No nail clubbing or nicotine
stains were seen, with capillary refill time less than 2s. There was no palmar erythema,
leukonychia, or asterixis. The radial pulse was regular with a pulse rate of 80 bpm, with normal
volume and character. Respiratory rate was 16 breaths per minute. No injection marks nor tattoo
marks seen.
There was no conjunctival pallor or scleral icterus nor flushing of the face. Upon inspection
of the mouth, Ms. A has good oral hygiene. She was not dehydrated evidenced by moist oral
mucosa and good skin turgor. There was no central cyanosis and angular stomatitis. There was no
muscle wasting of the temporalis. All cervical lymph nodes were not palpable.
There was no pedal oedema. Dorsalis pedis and posterior tibialis pulses were palpable with
normal volume and character bilaterally. No varicose veins seen.
Findings of organ/system examination: (in ward)
Nervous System

Higher cortical function

Patient is able to make eye contact, alert and conscious. Higher cortical function is intact.

Cranial Nerve examination

CN I No abnormal discharge, bleeding from nose. No loss of smell.

CN I is intact.
CN II Both pupil sizes are equal and normal. Vision is 6/6 on both eyes. Visual field
is not restricted. Normal consensual and direct light reflex. No visual neglect.
CN II is intact.
CN III, IV, VI No ptosis. Both eyes are able to fix and focus on finger while it moves across
horizontal and vertical plane.
CN III, IV, VI is intact.
 CN V No muscle wasting of masseter and temporalis muscles. Able to clench teeth,
though slight drooping of left angle was noted during clenching of teeth. No
absent of corneal reflex and jaw reflex.
Reduced sensation to light touch on left maxillary and mandibular regions.
Other regions are normal. CN V is intact.
CN VII Loss of left nasolabial fold. Able to raise eyebrow bilaterally. Able to close
eyes and resist from opening eyelid. Unable to blow out cheeks. Drooping of
left oral angle while trying to smile. CN VII is intact.
CN VIII Able to hear and repeat whispered voice.
CN VIII is intact.
CN IX, X Able to swallow.
CN IX is intact.
CN XI Able to turn head 90 degree to the right and left.
Able to shrug shoulder against resistance.
CN XI is intact.
CN XII No tongue deviation. However, patient had difficulty pushing tongue against
left cheek.
CN XII is intact.

Upper limb sensory and motor examination

Left upper limb Right upper limb

There is no scar, no muscle wasting, no involuntary movement, no
Inspection
fasciculation
SENSORY
Sensation Normal on dermatomes C5, C6, C7, C8, T1
Proprioception Normal Normal
MOTOR
Tone Normal Normal
Power 4/5 5/5
Reflex 1+ 2+
Lower limb sensory and motor examination

Left lower limb Right lower limb

There is no scar, no muscle wasting, no involuntary movement, no
Inspection
fasciculation
SENSORY
Sensation Normal on dermatomes L2, L3, L4, L5, S1
Proprioception Normal Normal
MOTOR

Tone Hypotonia Normal

Power 4/5 5/5

Reflex 1+ 2+
Babinski sign Negative Negative
Clonus test Negative Negative

Cerebellar examination

Test Result
Rapid hand movement Negative
Rapid alternating fingers Negative
Finger nose test Negative
Heel to shin test Negative
Heel to toe test Negative
Romberg’s test Negative
NIH Stroke Scale/Score (NIHSS)
Interpretation: Moderate stroke (5-15)

Cardiovascular system:
Inspection
The head of bed was elevated to 30°. No cardinal signs of infective carditis such as
Osler’s node, Janeway lesion or splinter haemorrhage. No signs of hypercholesterolemia such
as xanthelasma or corneal arcus. Apex beat were noted at left midclavicular line in fifth
intercostal space. No dilated vessels, chest deformity, or surgical scar seen on the chest.
Palpation
There was no radio-radial delay, radio-femoral delay and collapsing pulse. Jugular
venous pressure (JVP) was less than 2cm at bed elevated at 30°. Carotid pulse was felt on both
sides of the neck, no thrills noted. No parasternal heaves and no thrills palpable on mitral,
tricuspid, pulmonary and aortic area. No sacral oedema. Dorsalis pedis and posterior tibial pulse
palpable with good character and volume.
Auscultation
There were no carotid bruits heard bilaterally. On auscultation of all 4 areas, S1 and S2
could be heard with a regular rhythm and no murmur.
Respiratory system:
Inspection
There was no accessory muscle usage, flaring of nostrils or pursed lips breathing. Patient
was not on nasal prong or other oxygen supplement devices.
Palpation
There was no tracheal deviation or tracheal tug. Cricoid-sternal distance were 3 finger
breadths. There was no tenderness on light palpation of the chest. There was normal and equal
tactile fremitus. The chest expansion on 3 zones were adequate (3 cm) anteriorly and posteriorly.
Percussion
There was resonance on percussion at bilateral upper, middle, and lower zones
anteriorly and posteriorly, with normal liver and cardiac dullness.
Auscultation
Equal air entry and vesicular breathing could be heard bilaterally, with normal vocal
resonance. No other abnormal or added sound appreciated.

Abdominal examination
Inspection
Abdomen was symmetrical, not distended and moving with respiration. The umbilicus
was centrally located and inverted. No surgical scars, scratch marks, abnormal pulsation or
peristalsis seen. No visible veins or abnormal mass were seen on the abdomen.

Palpation
The abdomen was soft in all nine regions without tenderness, guarding or rigidity. There
was no hepatosplenomegaly. Both kidneys were not ballotable.

Percussion
Liver dullness was heard just below the costal margin. Resonance was heard in Traube’s
space. There were no shifting dullness and fluid thrills.

Auscultation
Normal bowel sound was heard. Liver bruit, renal bruit and aortic bruit were not heard.
Per rectal examination were not performed.
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SUMMARY OF CASE

Ms. A is a 75-year-old Malay lady with underlying well-controlled type 2 diabetes mellitus,
hypertension, and dyslipidaemia, who presented to Hospital Ampang with left sided hemiparesis
involving left lower face, upper and lower limb, associated with facial asymmetry, drooling of
saliva and dysarthria. She denied of symptoms of cerebellar ataxia, hypoglycaemia, syncopal
attack and meningoencephalitis. She also denied of symptoms of uncontrolled hypertension or
diabetes mellitus. Ms. A had family history of stroke. Physical examination revealed left sided
hemiparesis with hypotonia, without significant sensory disturbance. Blood pressure was 187/97
mmHg.

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PROVISIONAL AND DIFFERENTIAL DIAGNOSES

Provisional diagnosis

1. Pure motor left-sided hemiparesis due to lacunar infarct secondary to hypertensive

emergency

Supporting Evidence Evidence Against

• Left side face, upper and lower limb • No signs of upper motor neuron
weakness lesion (hyperreflexia, hypertonia,
• Absence of cortical signs – aphasia, positive Babinski reflex, clonus)
agnosia, neglect, apraxia, hemianopsia,
sensory deficit
• Risk factors: elderly age, type 2 diabetes
mellitus, hypertension, dyslipidaemia,
family history of stroke.
 • SBP > 180 mmHg with target organ
damage (stroke)

Differential Diagnosis:

2. Right cerebral stroke with left hemiparesis secondary to hypertensive emergency

Supporting Evidence Evidence Against

• Left sided body weakness with forehead • Lack of features of upper motor
sparing neuron lesion
• Risk factor of stroke • Absence of cortical symptoms

3. Right cerebral tumour

Supporting Evidence Evidence Against

• Left sided body weakness • Lack of common symptoms of

brain tumour – headache, seizure,
nausea, vomiting,
mental/behavioural changes, vision,
hearing, speech problem etc.

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 INVESTIGATION ON DAY OF ADMISSION
Investigation
Computed Tomography Scan of the Brain
Indications:
• To look for brain ischemia/infarct or intracranial haemorrhage
• To exclude stroke mimics such as tumour

Results: Unable to obtain image

Interpretation:
1. Periventricular lucencies may represent small vessel ischaemia.
2. Physiological calcifications at bilateral lentiform nuclei, pineal glands and choroid plexus
3. No acute intracranial bleed, no focal brain parenchymal lesion, no hypodense MCA and insular
ribbon signs to suggest hyperacute infarct.

Impression:
Bilateral thalamic hypodensity (calcification) with multifocal infarct

Electrocardiogram
Indications:
• To assess presence of infarction/ischemic changes/arrhythmia/other cardiac pathology

Result:
Interpretation:
This ECG shows regular sinus rhythm with regular R-R interval, estimated heart rate at 100 beats
per minute. There was no cardiac axis deviation. P waves are present at all leads, each was followed
by a QRS complex. PR interval is normal. QRS complexes are normal at all leads, except an
abnormal deep S wave at lead V3, though this finding was insignificant. There were no signs of
left ventricular hypertrophy as shown by normal S wave in lead V1. There were also no ischemic
changes such as deep q wave, ST segment elevation, T inversion, or ST segment depression.

Full Blood Count

• To ensure absence thrombocytopenia when considering fibrinolytic therapy

• To look at haemoglobin level to rule out anaemia
• To assess white cell count level for underlying infection/inflammation
Result:
Parameters Results Normal Range

RBC 4.87 3.86 - 5.62 × 10^6/uL

Haemoglobin 12.5 11.8 - 16.9 g/dL

Haematocrit 38.5 35.7 - 48.9%

MCV 79.1 80.6 - 95.5 fL

MCH 25.7 26.9 - 32.3 pg

MCHC 32.5 31.9 - 35.3 g/dL

Platelet 223 171 - 399 K/uL

RDW-CV 13.0 12.0 - 14.8%

WBC 5.4 4.1 - 11.4 K/uL

Absolute Neutrophil 3.4 3.9 - 7.1 K/uL

Absolute Lymphocyte 1.9 1.8 - 4.8 K/uL

Absolute Monocyte 0.6 0.4 - 1.1 K/uL

Absolute Eosinophil 0.1 0.0 - 0.8 K/uL

Absolute Basophil 0.0 0.0 - 0.1 K/uL

Interpretation: Normal haemoglobin and haematocrit level dismissed an anaemia. MCV and
MCH were borderline reduced, most probably insignificant.

Renal Profile
Indications:
• To assess kidney function and electrolyte balance especially when patient was
hypertensive/in hypertensive emergency/diabetic (for target organ damage/nephropathy)

Result:
 Parameters Results Normal Range

Urea 3.70 3.2 - 8.2 mmol/L

Sodium 141 136 - 145 mmol/L

Potassium 3.8 3.4 - 4.5 mmol/L

Chloride 105 98 - 107 mmol/L

Creatinine 71 62 - 115 mmol/L

Calcium 2.26 2.08 - 2.65 mmol/L

Magnesium 0.73 0.66 - 1.07 mmol/L

Phosphate Inorganic 1.02 0.78 - 1.65 mmol/L

Interpretation: Normal kidney function.

Liver Function Test

Indications:
• To assess liver function to rule out coagulopathy before starting antiplatelet drugs
• To assess liver function before staring statins

Result:
Parameters Results Normal Range

Bilirubin, Total 13.60 5 - 21 umol/L

Total Protein 65.6 57 - 82 g/L

Serum Albumin 40.3 32 - 48 g/L

Globulin 25 20 - 35 g/L

AG Ratio 1.26 1.2 - 2.5

Alkaline Phosphatase 87 46 - 116 IU/L

Alanine Transaminase 27 10 - 49 IU/L

Aspartate 32 8 - 33 IU/L
Transaminase
Interpretation: Normal liver function

Coagulation Profile

Indications:
• To rule out coagulopathies before starting fibrinolytic therapy
Result:
Parameters Results Normal Range

Activated Partial Thromboplastin Time 39.2 30.8 - 43.7 s

Prothrombin Time 12.9 11.0 - 15.4 s

International Normalised Ratio 0.98 < 1.1

Interpretation: No coagulopathies.

Lipid profile
Indication:
• To assess dyslipidaemia

Result:
Parameters Results Normal Range

Total Cholesterol 4.55 0.65 – 5.20 mmol/L

Triglycerides 4.05 0.11 – 1.70 mmol/L

HDL cholesterol 0.63 1.20 – 3.34 mmol/L

LDL cholesterol 2.07

Interpretation: Derangement in triglyceride and HDL cholesterol level. As this patient has very
high CV risk based on Framingham risk score (21.4%; > 20%), the target LDL level should be <
1.8. Therefore, it can be deduced that this patient has uncontrolled dyslipidaemia.

Fasting blood glucose

Indication:
• To assess diabetes mellitus
Result: 6.0 (normal)

Management & Follow Up

Upon initial encounter at ED, ECG and CT brain was ordered for Ms. A. Blood was taken
immediately to be sent for investigation. Vital signs were closely monitored. Antihypertensive
drug was put on hold after CT scan was done. Ms. A was then referred to medical ward once her
condition stabilises. In the ward, thorough neurological examination was performed. GCS charting
was ordered. The following medication was prescribed for this lady:

T. Cardiprin 1/1 OD
T. Simvastatin 40 mg OD

Ms. A’s DXT level were made sure to kept between 8 – 10 and S/C Actrapid 6u was kept on hold
if Ms. A’s dextrose level were to increase to > 12. She was then referred to a speech therapist and
physiotherapy. Her blood pressure had dropped to 154/74 mmHg by the end of 1st day.

On the 2nd day, Ms. A was alert with full GCS. BP had dropped to 142/86 mmHg. Left-sided
weakness and hypotonia was still present, with power of 4/5 on left upper and lower limb.
Medications were started for Ms. A as follows:

T. Plavix 75 mg OD for 6 weeks

Lifelong T. Cardiprin 100 mg OD
T. Simvastatin 40 mg ON
T. Amlodipine 10 mg OD
T. Pantoprazole 40 mg OD

Moving to the 4th day of admission, Ms. A’s tone and reflexes were found normal, though the
power of left limbs were still 4/5. She was able to speak in full sentence clearly. Blood pressure
was 139/74 mmHg. Ms. A was allowed to be discharged with follow up arranged at 3 months later.