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integrated clinical round Clinical Retina Notes ophthalmology medical students 5th grade faculty of medicine KafrELSheikh university

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Acute Limb Weakness case presentation PBL session 3rd year neuro ophthalmology new mansoura university A 54-year-old man, Mr. Stephen Smith, was brought by ambulance to the ‎Emergency Department. He had woken up from sleep with slurring of speech ‎and weakness of his right arm and leg. His wife was extremely distressed as Mr ‎Smith had been perfectly well the previous night when he went to sleep. Within ‎‎20 minutes after the initial call was made Mr. Smith was admitted to the ‎Emergency Department and was reviewed by the SpR covering the Regional ‎Specialist Stroke Unit. Mr. Smith had been on regular antihypertensive ‎medication (lisinopril) for 8 years. He smoked 5-8 cigarettes a day and was a ‎social drinker consuming about 6 units of alcohol a week. He was not diabetic. ‎ His Serum lipids were checked and was advised to reduce weight and ‎started on a Statin (Simvastatin). There was no family history of hyperlipidaemia ‎but his grandfather died after a Stroke. Mr. Smith had an urgent appendectomy 1 ‎week and made an uneventful recovery. He lives with his wife in a 4-bedroom ‎detached house. ‎ Neurological examination showed that Mr. Smith was fully conscious and ‎alert. He had an upper motor neuron facial palsy on the right side. He had ‎expressive dysphasia but appeared to comprehend speech. He was just able to lift ‎his right arm off the bed for a short period but had no grip. His right leg was ‎weak. ‎ Reflexes on the right side were exaggerated and his right plantar was ‎extensor. He responded to touch and pin prick equally on both sides. He either ‎had visual inattention or a visual field defect on the right side. He had no ‎papilloedema His blood pressure was 164/96, pulse 84 per min, regular. Other ‎systems were entirely normal. ‎ ECG and all routine blood tests were performed. An emergency CT scan ‎was requested and even though the scan was normal the SpR ruled out ‎emergency thrombolysis in this instance. Mr. Smith was admitted to the Acute ‎Stroke Unit and was seen by the Stroke Consultant. Mr. Smith remained fully ‎conscious and alert but had some difficulty in swallowing. Hence an intravenous ‎infusion was commenced and an alternate strategy was adopted for providing his ‎nutritional requirements. A carotid Doppler scan was requested. ‎ After 3 weeks, Mr. Smith seemed to make good progress and the MDT ‎meeting recorded a consistent improvement in his Barthel Index. The Stroke ‎Team met him with his wife and discussed arrangements for discharge home. His ‎wife was keen to know what support measures were available to them when Mr. ‎Smith returned home. She also wanted to know about the risk of a future stroke ‎and how this could be cut down. ‎ ILOs:- ‎ ‎1- Consider the differential diagnosis of speech. ‎ ‎2- Discuss the risk factors for stroke and primary prevention of stroke. ‎ ‎3- Discuss the overall management of a patient with an acute stroke. ‎ ‎4- Complications of stroke

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