CASE PRESENTATION - STROKE
Patient’s details
Name: P.J.
IC Number: -
Age: 41 years old
Gender: Female
Occupation: Fulltime housewife
ADL-independent
Right hand dominant
Chief complaint
A 41-year-old lady, an active smoker of 0.5 pack years with NKMI presented with sudden right sided
body weakness for 1 day duration.
HOPI
Right sided body weakness
Onset: Sudden (1/7), morning around 630am while getting ready to drive a car, previously
was relatively well.
Duration: Persistent, no progressive improvement nor deterioration/ worsening
Site: Right sided only, UL affected more than LL (while R hand is already limp, she can still
walk for the next hour) —> current condition: UL regain function earlier than LL, able to
grasp
Associated symptoms
o Preceding 2-3/7 associated with numbness and pin-prick sensation over the right
hand, most prominent at her fingertips
o That same 2-3/7, c/o mild fever for 2-3 days with no recorded temperature, no chills
& rigor, relieved temporarily by PCT, unidentified source of infection, no hx of sick
contact or attending large gathering previously
o After the event, there was slurred speech (dysarthria or espressive aphasia), and
the patient becomes stuporous and less responsive. Otherwise, patient were able to
remain conscious throughout the ride to ETD upon being called.
o She was seen salivating due to facial droopiness. However, her husband denied any
choking of saliva.
o At the ETD, she had urinary incontinence without her own awareness.
o Husband noticed patient seems to be confused and not able to recall her children
and husband.She were also unable to vocalise
Relevent negative
o No loss of balance
o No LOC
o Unsure of vision impairment & visual symptoms (hx from informant – husband)
Systemic review
General: Fever 3/7, no history of accidents, trauma or any head injury, no constitutional symptoms
Respi: No SOB/ tachypnea, no respiratory depression, no c/o CP, no URTI symptoms
CVS: No palpitation, no reduced effort tolerance, no irrgeular heart beat
CNS: Occasional mild headache, no hx of vomiting, no visual disturbance, no hx of fitting
GU: Incontinence one time at ETD (before CBD insertion), prior to event no dysuria, no hematuria,
no hesitancy (no UTI symptoms)
MSK: frequent lower mechanical back pain, frequent leg pain, no bone pain or joint pain
GI: no NVD, no constipation, no abdominal pain or swelling
, Past medical history
NKMI, not on any medication previously
No FDA
Not on OCP
Social history
Active smoker of Rev Cigarrattes for 3 sticks/ day since 5 years ago (5 pack years)
Non-alcoholic
Non-IVDU or recreational drug user
Family history
15 occupants in a household
Blessed with 4 children – 20, 18, 12, 6
Financially stable
Mother was diagnosed with DM, died at the age of 72 from stroke
No family history of malignancy
Personal history
Working as a fulltime housewife
Pregnant 4 times deliver w/o complication, last pregnancy was 2016, complicated with DVT
Never use OCP as contraception method
Patient’s details
Name: P.J.
IC Number: -
Age: 41 years old
Gender: Female
Occupation: Fulltime housewife
ADL-independent
Right hand dominant
Chief complaint
A 41-year-old lady, an active smoker of 0.5 pack years with NKMI presented with sudden right sided
body weakness for 1 day duration.
HOPI
Right sided body weakness
Onset: Sudden (1/7), morning around 630am while getting ready to drive a car, previously
was relatively well.
Duration: Persistent, no progressive improvement nor deterioration/ worsening
Site: Right sided only, UL affected more than LL (while R hand is already limp, she can still
walk for the next hour) —> current condition: UL regain function earlier than LL, able to
grasp
Associated symptoms
o Preceding 2-3/7 associated with numbness and pin-prick sensation over the right
hand, most prominent at her fingertips
o That same 2-3/7, c/o mild fever for 2-3 days with no recorded temperature, no chills
& rigor, relieved temporarily by PCT, unidentified source of infection, no hx of sick
contact or attending large gathering previously
o After the event, there was slurred speech (dysarthria or espressive aphasia), and
the patient becomes stuporous and less responsive. Otherwise, patient were able to
remain conscious throughout the ride to ETD upon being called.
o She was seen salivating due to facial droopiness. However, her husband denied any
choking of saliva.
o At the ETD, she had urinary incontinence without her own awareness.
o Husband noticed patient seems to be confused and not able to recall her children
and husband.She were also unable to vocalise
Relevent negative
o No loss of balance
o No LOC
o Unsure of vision impairment & visual symptoms (hx from informant – husband)
Systemic review
General: Fever 3/7, no history of accidents, trauma or any head injury, no constitutional symptoms
Respi: No SOB/ tachypnea, no respiratory depression, no c/o CP, no URTI symptoms
CVS: No palpitation, no reduced effort tolerance, no irrgeular heart beat
CNS: Occasional mild headache, no hx of vomiting, no visual disturbance, no hx of fitting
GU: Incontinence one time at ETD (before CBD insertion), prior to event no dysuria, no hematuria,
no hesitancy (no UTI symptoms)
MSK: frequent lower mechanical back pain, frequent leg pain, no bone pain or joint pain
GI: no NVD, no constipation, no abdominal pain or swelling
, Past medical history
NKMI, not on any medication previously
No FDA
Not on OCP
Social history
Active smoker of Rev Cigarrattes for 3 sticks/ day since 5 years ago (5 pack years)
Non-alcoholic
Non-IVDU or recreational drug user
Family history
15 occupants in a household
Blessed with 4 children – 20, 18, 12, 6
Financially stable
Mother was diagnosed with DM, died at the age of 72 from stroke
No family history of malignancy
Personal history
Working as a fulltime housewife
Pregnant 4 times deliver w/o complication, last pregnancy was 2016, complicated with DVT
Never use OCP as contraception method
