STROKE

GROUP D

PATIENT PARTICULARS
NAME
AGE
SEX
RELIGION
RACE
MARITAL STATUS
OCCUPATION
ADDRESS
DATE OF ADMISSION
DATE OF CLERKING

: Mr A
: 71 years old
: Male
: Islam
: Dusun
: Widower
: Retired politician
: Kg Ungkudou, Ranau
: 25/12/2014
: 30/12/2014

CHIEF COMPLAINT
Right upper limb and left lower limb
weakness upon waking since 10pm on
23/12/14.

HISTORY OF PRESENT ILLNESS

The patient reported to have sudden onset of weakness of the right upper limb and
left lower limb upon waking since 10pm on 23/12/2014.
-The patient experienced no trauma and no loss off consciousness.
-No headache, no blurring of vision, no nausea or vomiting and no chest pain.
The patient has HPT and DM since 1990s, stage II CKD and history of stroke in
2006 and 2007. He only managed to go to Ranau Hospital the next morning
because of no transport. He arrived at the ETD of QEH2 at 6pm (24/12/14). He had
high blood pressure (157/64 mmHg) and was hypoglycaemic (2.8 mmol/L) so his
initial management was:1) IV DXT 50% 50cc

4) Withold oral hypoglycaemic agents

2) Send for CT brain

5) IVD 5 pints normal saline/day

3) Hourly vital signs

6) Refer medical

HISTORY OF PRESENT ILLNESS

23/12/2014
Right upper limb
and left lower
limb weakness

10pm

24/12/2014
ETD QEH2

6pm

25/12/2014
Admitted to
MMU QEH2

3.20pm

The patient was then referred to medical and

transferred to the MMU the next morning at
3.20am (25/12/14).

HISTORY OF PRESENT ILLNESS

1)
2)
3)
4)

Upon admission, the doctor in charge noted the following:The patient was alert and able to provide full history;
Facial asymmetry and slurred speech;
Systolic murmur;
Ronchi and bilateral crepitations.
UPPER LIMB

LOWER LIMB

LEFT

RIGHT

LEFT

RIGHT

TONE

Hypotonia

Normal

Normal

Hypotonia

REFLEX

Normal

Normal

Normal

Normal

UMN/LMN
POWER
SENSORY

Hoffmann negative
3/5

Plantar response (Downgoing)

No clonus
5/5

5/5
Intact

3/5

HISTORY OF PRESENT ILLNESS

His vital signs and DXT were monitored and were given
the following medications:1) T. Aspirin 150mg OD
2) T. Amlodipine 5mg OD
3) T. Omeprazole 20mg OD
4) T. Simvastatin 20 mg ON
On the 26/12/14, the patient experienced cough and
wheezing but was afebrile. He was started on IV
Augmentin 1.2g TDS.
He still had mild cough but no other active complaints.

PAST MEDICAL HISTORY

The patients has hypertension and diabetes
diagnosed in the 1990s and is on
medication. He has stage II CKD and
history of stroke:
a)2006 - RUL and LL weakness
b)2007 LUL and RUL weakness
He has no history of accidents or trauma.

PAST SURGICAL HISTORY

The patient reported of no past surgeries.

MEDICATION , ALLERGY AND

TREATMENT HISTORY
He is taking medications for his HPT and
DM.
No known food or drug allergies.

FAMILY HISTORY
He is the 9th out of 10 siblings.
No known family history of HPT, DM and
stroke in his family.

SOCIAL HISTORY

The patient is a retired politician and has 4

children.
His wife passed away last year due to stroke.
He is financially supported by his pension and
his children.
He lives with his son but the son is not at
home for most of the day and the patient
cooks for himself during the day.
He does not smoke or consume alcohol.

SYSTEMIC REVIEW
Cardiovascular System:

No chest pain
No paroxysmal noctunal dyspnoea
No ankle swelling
No palpitations
No syncope

 Respiratory System:

Mild cough
Wheezing has resolved
No dyspnoea
No hemoptysis
No hoarseness

 Gastrointestinal System:

No abdominal pain
No loss of appetite
No weight loss
No change in bowel habit
No haematemesis
No malaena
No jaundice

 Genitourinary system:

No haematuria
No polyuria
No nocturia
No hesitancy
No dribbling
No urine retention
No urine incontinence
No dysuria
No loin pain.

 Haematological system:
No symptoms of anemia, no easy bruising, no lymph
node enlargement, no bone pain, no paraesthesiae,
no skin rash.

Musculoskeletal system:
No pain, stiffness, or swelling of joints, no muscle
pain.

GENERAL EXAMINATION
General appearance
The patient was lying on his bed at 45o. He was alert, well orientated and responsive. He had
nasal prongs on and a cannula on his left hand that was connected an IV drip with Augmentin.
General examination
a)Hand : No peripheral cyanosis, no clubbing, no fine tremor, no flapping tremor.
b)Face : Symmetrical and no abnormalities
c)Eyes : No jaundice, mild conjunctival pallor
d)Tongue:No central cyanosis
e)Neck : JVP not raised, no lymph node enlargement
f) Legs : No pitting edema.
Vital signs:
a)Pulse - 88 beats/min, regular rhythm, moderate volume, normal character, no thickening
b)RR - 20 breaths/min
c)BP - 124/70 mmHg
d)Temperature - 37.0 degrees Celsius

MENTAL STATE EXAMINATION

The patient appears well groomed.
He was calm, alert, responsive and
receptive.
Oriented to time, place and person.
His speech was slow not slurred.
Recall and memory is intact.

CRANIAL NERVES
Cranial Nerves

Results

CN I

Sense of smell was intact in both sides of nose

CN II

- The result of visual acuity was normal for both eyes.

- The visual fields of four quadrants were not impaired

CN III
CN IV
CN VI

- Accommodation: Convergence of both eyes and

pupillary constrictions were present
- Light reflex: both direct and consensual response to
light was normal (pupil constricts) .
- Nystagmus and diplopia absent

CN V

- Normal strength of temporal and masseter muscles

on both sides.
- The pain sensation for all three divisions was intact.

CRANIAL NERVES ctd.

CN
CN VII

Results
- Function of facial muscles are all intact.
- Sense of taste is normal in the anterior 2/3 of the tongue.

CN VIII - Sense of hearing was intact in both ears.

CN IX
CN X

- No dysphagia and hoarseness of voice

- Able to cough and drink water.
- Sense of taste is normal in posterior 1/3 of the tongue.

CN XI

- No atrophy or asymmetry of trapezius muscle.

- No atrophy of asymmetry of sternocleidomastoid muscle.
- Can resist to the force implied against shrugging of shoulder.

CN XII

- No tongue deviation
- Speech was normal (no dysarthria)

UPPER LIMB EXAMINATION

INSPECTION AND PALPATION

- Muscle bulk is bilaterally equal, no wasting, no

muscle hypertrophy, no tenderness, no scars
and deformities.
- Fasciculations, myoclonic jerks and tremors
are absent.
- Dyskinesias are absent.

UPPER LIMB (MOTOR)

TONE
DEEP TENDON
REFLEX
POWER

COORDINATION

LEFT UPPER LIMB

RIGHT UPPER LIMB

Normal muscle tone

Normal muscle tone

Biceps jerk (N)

Triceps jerk (N)
Supinator jerk (N)

Biceps jerk (N)

Triceps jerk (N)
Supinator jerk (N)

The power of individual The power of individual

muscle groups of the muscle groups of the right
left upper limb is 5/5.
upper limb is 5/5.
Rebound phenomenon absent
No dysmetria
No dysdiadochokinesis

UPPER LIMB (SENSORY)

The sense of pain,

proprioception and light
touch according to the
dermatomes are normal
in both limbs.

LOWER LIMB EXAMINATION

INSPECTION & PALPATION
- Muscle bulk is bilaterally equal, no wasting,
no muscle hypertrophy.
- Fasciculations, myoclonic jerks and tremors
are absent.
- Dyskinesias are absent.

LOWER LIMB (MOTOR)

LEFT LOWER LIMB
TONE

Normal muscle tone

RIGHT LOWER LIMB

Normal muscle tone

Knee and ankle clonus absent

DEEP TENDON
REFLEX
PLANTAR
RESPONSE
POWER

Knee jerk (N)

Ankle jerk (N)

Knee jerk (N)

Ankle jerk (N)

Downgoing

Downgoing

The power of individual The power of individual

muscle groups of the muscle groups of the right
left upper limb is 5/5.
upper limb is 5/5.

COORDINATION No dysmetria or dyssynergia of left lower limb.

LOWER LIMB (SENSORY)

Sensory functions are

intact on both lower
limbs

CASE SUMMARY
The patient is a 71 year old man presented with right
upper limb and left lower limb weakness upon waking
since 10pm on 23/12/2014. He has hypertension on
medication, diabetes currently on insulin and stage II
CKD on follow up at Hospital Ranau. He has history of
stroke in 2006 and 2007. On the 26/12/14, the patient
experienced cough and wheezing. On examination, the
tone, power, reflex, coordination and sensation is
normal. Currently, patient is stable and well except for his
mild cough.

INVESTIGATIONS
IMAGING
ECG (sinus rhythm, no ischaemic changes, anterior ST elevation LVH)
CT brain (hypodensities at pons, right basal ganglia, anterior limb of right
internal capsule and right head caudate nucleus multifocal infarcts and
generalised cerebral atrophy)
Chest X-ray

OTHERS
Full Blood Count
PP/APTT
Liver Function Test (A/G ratio 0.9; AST 99 U/L)
UFEME
BUSE (K 3.0 mmol/L)
Lipid profile (Low HDL 0.89 mmol/L)

DIAGNOSIS
PROVISIONAL DIAGNOSIS:
Minor Ischaemic stroke

PLAN AND MANAGEMENT

Cont. IV Augmentin 1.2g TDS

Cont. Neb VAN 8 hourly
Cont. DXT monitoring
Cont. meds:

s/c actrapid 10U TDS

Mist KCl 1.5g TDS (if K+ still low)
T. Amlodipine 10mg OD
T. Clopidogrel 75mg OD
T. Perindopril 40mg OD
T. Metformin 1g BD

Cont. 2 pints normal saline/day IVD and encourage orally.

Trace investigations
Aim for metformin and insulatard/gliclazide upon discharge.

DISCUSSON
CLINICAL DEFINITION
Complete stroke = Deficit has become
maximal, usually within 6 hours.
Progressing stroke = focal deficit worsens
after the patient first presents.
Minor stroke
= Patients recover without
significant deficit, usually within one week.
TIA = focal deficit lasts from a few seconds to
less than 24 hours.

DISCUSSION
PATHOPHYSIOLOGY
Ischaemic stroke = due to inadequate blood
flow (85%)
Haemorrhagic stroke = rupture of blood
vessel within brain parenchyma (15%)

DISCUSSION
Clinical presentation depends on which
arterial territory is involved and size of lesion.
Cerebral hemisphere

Unilateral motor deficit, higher

cerebral function deficit
(aphasia or neglect), visual
defect

Brain stem or
cerebellum

Ataxia, diplopia, vertigo and/or

bilateral weakness.

Hypodensities at pons, right basal ganglia, anterior limb

of right internal capsule and right head caudate nucleus

DISCUSSION
RISK FACTORS
FIXED
Age
Male > Female
Previous vascular event
Hereditary
Race
High fibrinogen

MODIFIABLE
High BP
Heart disease
Diabetes mellitus
Hyperlipidaemia
Smoking
Excess alcohol consumption
Polycythaemia
Oral contraceptives
Social deprivation

DISCUSSION
The following investigations for patients with
ischaemic stroke are recommended to:1. Confirm the diagnosis
2. Determine the stroke mechanism
3. Risk stratification and prognostication
4. Identify potentially treatable large obstructive
lesions of the cerebrovascular circulation

DISCUSSION