Presenting Complaint

• You are concerned about the sudden loss of hearing in your left ear and you are self-conscious about how the left side of your face droops when you smile

History of Presenting Complaint

• Site: Left side of your face droops when you smile and you are unable to talk properly. You can raise both of your eyebrows (Only say if asked specifically)
• Onset: You noticed the symptoms when you woke up in the morning and went to brush your teeth. The symptoms have been constant and have started around 4 hours ago
• Triggers: No previous falls and infections and fevers and episodes of diarrhoea
• Associated Symptoms/Neurological System Review: You have not had any fits, faints, funny turns, tremors and changes in vision and sensation
• Severity: The facial weakness is ruining your quality of life as you are unable to chew food and drink any fluids. So, it is a 10/10 in ruining your quality of life

System Review

• B Symptoms: No fever, lethargy, anorexia, weight loss and night sweats
• GI Symptoms: No changes in bowel and bladder habit but you have some nausea and vomiting
• Cardio Symptoms: You have no chest pain, palpitations and dizziness
• Respiratory Symptoms: You have no shortness of breath, cough and breathing difficulty
• Otherwise well, no other problems

Past Medical History

• Poorly controlled hypertension and diabetes
• No known hospital admissions and past surgeries
• High cholesterol
• Atrial fibrillation
• No previous episodes of facial paralysis and neurological disease

Drug History

• Ramipril: for the high blood pressure
• Atorvastatin: for the high cholesterol
• Metformin: for the high blood sugar
• Apixaban: for the atrial fibrillation
• You are not compliant with your medications. (Only say if specifically asked)

Allergies

• No known drug allergies

Social History

• No recent travel history.
• You are an ex-smoker and have stopped for 10 years. Before you smoked 5 a day for 10 years (only if asked)
• Never drunk alcohol
• Never taken any recreational drugs
• Works 24/7 as a digital currency trader and job is stressful and not active
• Live at home with family

Family History

• High blood pressure and diabetes runs in the family
• No history of neurological disease
• No history of cerebrovascular disease and cancer

ICE

• Ideas: You believe this is a stroke

• Concerns: You are worried about not being able to talk and hear properly

• Expectations: You want medication and treatment as soon as possible

Vitals

• HR:  95 bpm
• BP: 141/91
• SpO2: 99%
• Temperature: 36.6℃
• Respiratory Rate: 16 breaths per min
• GCS: 15/15

Head and neck examination

• No lymphadenopathy in head and neck
• No abnormalities detected when inspecting the throat

Cardiovascular exam

• • Pulse –  Heart Rate is 95 bpm, pulse is irregular irregular
  • Heart Sounds – S1 and S2 Normal and no additional heart sounds
  • No other abnormalities were detected

Neurological exam

Cranial Nerve Examination:

• • Cranial Nerve 1-6: All Normal functions
  • Cranial Nerve 7: Able to raise their eyebrows on both sides. Unable to smile or puff out their cheek on the left side. Patient also reports a loss of taste
  • Cranial Nerve 8: Patient cannot hear out of her left ear. Weber’s test lateralizes to the right ear. Patient Rinne test is positive on both sides. Patient displays some unsteadiness as well
  • Cranial Nerve 9-12: All normal function

Upper Limb and Lower Limb Examination

Pin-prick, vibration and proprioception sensation normal

Upper limbs:

No scarring, muscle wasting, tremor and fasciculations

Increased tone bilaterally.

MRC Power of 2 out 5 in all joints movements of right upper limb

Hyperreflexia of right upper limb

Pin-prick, vibration and proprioception sensation normal

Lower limbs:

No scarring, muscle wasting, tremor and fasciculations

Increased tone bilaterally

MRC Power of 4 out 5 in all joints movements of right lower limb

Normal reflexes and upgoing plantar of right foot

Examiner Questions:

1) What is the most likely diagnosis and explain why?

• Stroke – Due to the sudden onset of the symptoms. Also, the symptoms being localised to just one side of the face and the ear with no tremor and fasciculation in the limbs indicate stroke over motor neurone disease and multiple sclerosis. This is not a TIA as the symptoms are ongoing. Also, the patient has risk factors for a stroke like diabetes, hypertension, smoking history and atrial fibrillation. 

2) What are the first suitable investigations for this patient in the hospital and why?

• We will do blood glucose first because low blood glucose can mimic the symptoms of the stroke, and we want to rule low blood glucose first.

3) What imaging is most appropriate here and why? 

• A non-contrast CT head to determine if stroke is ischaemic or haemorrhagic stroke as the patient is on apixaban (an anticoagulant).

4) Given the suspected diagnosis of an ischaemic stroke, how do you manage this patient?

• Manage using an A-E approach.

• Thrombolysis (using IV alteplase) and thrombectomy is indicated as the patient arrived within the 4.5-hour window and haemorrhagic stroke is excluded.

• After the thrombolysis has been done, we will admit the patient in a stroke ward for further monitoring.

• We will have a disability screen done for the patient and have SALT help with their speech and swallow rehabilitation.

• Encourage the patient to manage their diabetes and high blood pressure as well.

• Prophylactic apixaban monotherapy (as AF is the likely cause of the stroke here). Provide patient support so they take the medications appropriately.

• Consider treatments for controlling the AF e.g. ablation therapy, etc.