65 years of male having stroke seen by family in the morning after sleeping peacefully he is having slurred speech paralysis of lower 1/2 of face he was conscious but difficult in speech what will b the cheip complaint negative history with reason and rullout other systems and examination how to written his examination in detail patient is diabetic since 15 years and have hypertensive since 3 years
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I now have sufficient information from the textbooks to write a comprehensive, well-structured clinical case write-up. Let me compile this into a detailed, properly formatted response.
Clinical Case Write-Up: 65-Year-Old Male with Acute Stroke
CHIEF COMPLAINT (C/C)
"Slurred speech and weakness of the right lower half of face noticed by family members this morning, with difficulty in communication."
Write it exactly as the patient/family presented it. In this case, the family found him in the morning - this is called a "wake-up stroke" or "wake-up onset stroke."
HISTORY OF PRESENT ILLNESS (HPI) / PRESENTING COMPLAINTS
Write the HPI in this structured way:
Mr. X, 65 years male, known diabetic (15 years) and hypertensive (3 years), was apparently well the previous night when he went to bed. He was found by his family members in the morning with:
- Slurred speech (dysarthria) - sudden onset, discovered on waking
- Paralysis/weakness of the lower half of the right face - upper face spared (upper motor neuron pattern - forehead sparing)
- Conscious but difficulty in speech - oriented but unable to communicate clearly
Time of onset: Unknown (last known well = previous night before sleep). This is a wake-up stroke - time of last seen normal is the time he went to bed.
Duration: Persistent at time of presentation
Progression: No improvement since noticed
NEGATIVE HISTORY (with reasons for each)
The negative history is taken to rule out differentials, establish severity, and guide management. Every negative point must have a clinical reason for asking.
| Negative History | Reason for Asking |
|---|---|
| No headache | Subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH) typically present with sudden severe "thunderclap" headache. Absence makes hemorrhagic stroke less likely. |
| No vomiting | Raised intracranial pressure (ICH, SAH, space-occupying lesion) causes vomiting. Absence favors ischemic over hemorrhagic stroke. |
| No seizures | Seizures can cause Todd's paralysis (post-ictal weakness mimicking stroke). Absence helps rule out this mimic. |
| No loss of consciousness | Massive hemorrhagic stroke or brainstem involvement causes loss of consciousness. Patient was conscious throughout. |
| No fever | Septic emboli (infective endocarditis), CNS infection (meningitis, encephalitis), and stroke recrudescence in the setting of infection must be ruled out. |
| No recent trauma to head or neck | Traumatic subarachnoid hemorrhage or carotid/vertebral artery dissection from neck trauma can cause stroke. |
| No palpitations or irregular heartbeat | Atrial fibrillation is the most common cardiac source of cardioembolic stroke. Its absence lowers (but does not exclude) embolic source. |
| No recent surgery | Perioperative stroke risk from hypoperfusion, embolism, or hypercoagulable state. |
| No recent chiropractic manipulation of neck | Vertebral/carotid artery dissection is a known complication of neck manipulation, especially in elderly. |
| No visual disturbance | Monocular blindness (amaurosis fugax) or hemianopia suggests anterior circulation or PCA involvement. Absence helps localize lesion. |
| No dysphagia | Posterior circulation (vertebrobasilar) stroke - especially PICA/lateral medullary - causes dysphagia. |
| No diplopia or vertigo | Posterior circulation stroke (brainstem involvement) causes diplopia, vertigo, and ataxia. Absence favors anterior MCA territory. |
| No limb weakness | In this case, if arm or leg weakness is absent, it helps localize the lesion to the facial cortical representation only (partial MCA or lacunar). If present, it points to larger MCA territory. |
| No bladder or bowel disturbance | Spinal cord pathology (cervical myelopathy) can mimic upper motor neuron weakness. |
| No recent drug change or missed antihypertensive/antidiabetic medications | Hypoglycemia (from missed meals + diabetes medications) is an important and treatable stroke mimic. Hypertensive urgency from missed BP medicines can precipitate hemorrhagic stroke. |
| No history of similar episodes in the past (TIAs) | Previous TIAs warn of impending stroke and indicate the vascular territory at risk. |
| No oral contraceptive use (in spouse - not applicable here) / No substance use | Cocaine, amphetamines cause hemorrhagic stroke; relevant in younger patients. |
SYSTEM REVIEW / RULING OUT OTHER SYSTEMS
Cardiovascular System
- No chest pain, palpitations, or breathlessness - to rule out concurrent MI, AF, or cardiac source of embolism
- No history of rheumatic heart disease or valve replacement - to rule out valvular embolism
- No orthopnea/PND - to rule out congestive cardiac failure as embolic source
Respiratory System
- No cough, hemoptysis - to rule out lung infection / paradoxical embolism
- No shortness of breath at rest - to rule out hypoxia contributing to cerebral ischemia
Gastrointestinal System
- No abdominal pain, vomiting, or altered bowel habits - to rule out GI cause of systemic illness
- Relevant because anticoagulation/thrombolysis used in stroke can cause GI bleeding - baseline GI history needed
Genitourinary System
- No dysuria, hematuria - baseline needed if anticoagulation/tPA is to be started (recent GU bleed is a contraindication to tPA)
Musculoskeletal System
- No joint pain or rash - to rule out vasculitis (SLE, antiphospholipid syndrome) as cause of stroke in appropriate context
Endocrine System
- Diabetes for 15 years - long-standing DM accelerates atherosclerosis and is a major independent risk factor for ischemic stroke (Washington Manual of Medical Therapeutics)
- Ask about glycemic control: frequent hypoglycemic episodes? - hypoglycemia must be ruled out immediately as a stroke mimic (blood glucose on admission is mandatory)
- Hypertension for 3 years - the single most important modifiable risk factor for both ischemic and hemorrhagic stroke; ask about compliance with medications
Neurological System (Screening of other functions)
- No hearing loss, tinnitus - to rule out posterior circulation involvement
- No memory disturbance, behavioral change prior to this event - to rule out pre-existing dementia or space-occupying lesion
- No limb incoordination or gait unsteadiness - to rule out cerebellar or posterior circulation stroke
PAST HISTORY
- Diabetes mellitus - since 15 years; ask what medications (insulin vs oral hypoglycemics), frequency of monitoring, HbA1c levels, complications (neuropathy, nephropathy, retinopathy)
- Hypertension - since 3 years; which antihypertensives, compliance, home BP readings, last check
- No known history of prior stroke or TIA
- No known cardiac disease (AF, valvular disease, heart failure)
- No known dyslipidemia (ask - very common in DM+HTN patients)
- No previous surgeries
PERSONAL HISTORY
- Diet: Vegetarian / Non-vegetarian (diet compliance in diabetes)
- Tobacco use: Smoking (pack-years), tobacco chewing - risk factor for stroke
- Alcohol use: Chronic heavy alcohol is a risk factor
- Sleep pattern: Was he sleeping normally last night? (Wake-up stroke)
- Exercise: Sedentary lifestyle is a stroke risk factor
FAMILY HISTORY
- Any first-degree relatives with stroke, MI, DM, HTN, or hypercoagulable disorders
DRUG HISTORY
- Current medications: Antidiabetics (Metformin, sulfonylurea, insulin), antihypertensives (ACE inhibitor, ARB, CCB, beta-blocker, diuretic)
- Any antiplatelet or anticoagulant use?
- Any statins?
- Any NSAIDs - relevant to bleeding risk
EXAMINATION - HOW TO WRITE IT
1. GENERAL EXAMINATION
Write it in this standard order:
On general examination, the patient was conscious, oriented to time, place, and person. He was in mild distress due to difficulty in communication. He was not pale, not icteric, not cyanosed, not clubbed. No lymphadenopathy. No peripheral edema. No signs of dehydration.
- Built: Average built, adequately nourished
- Decubitus: Lying comfortably in bed, supine
- Pulse: Note rate, rhythm (regular/irregular - to detect AF), character, and volume. All four limb pulses to be felt. Check for radio-radial and radio-femoral delay.
- Example: "Pulse rate 78/min, regular rhythm, normal volume and character. All peripheral pulses present and equal."
- Blood pressure: Record in BOTH arms (carotid/subclavian stenosis causes asymmetry)
- Example: "BP 160/96 mmHg in right arm, 158/94 mmHg in left arm." (Hypertension - likely elevated)
- Respiratory rate: Note rate and pattern
- Temperature: Afebrile (fever would suggest infection)
- SpO2: To assess oxygenation
- Random blood glucose: Must be done at bedside immediately (to rule out hypoglycemia as stroke mimic - this is a diabetic patient on medications)
2. SYSTEMIC EXAMINATION
A. NERVOUS SYSTEM EXAMINATION (most detailed - this is the core)
Higher Mental Functions:
- Consciousness: GCS (E_V_M_) - e.g., E4V4M6 = GCS 14 (conscious, some speech difficulty)
- Orientation: Time, Place, Person - intact
- Memory: Recent and remote - briefly tested
- Language/Speech:
- Dysarthria (slurred speech) - PRESENT - patient has difficulty articulating words but content of speech may be intact (vs aphasia where content is affected)
- Test: Ask patient to repeat "British Constitution" or count 1 to 10
- Note: Dysarthria here is due to weakness of lower facial muscles (UMN)
- Screen for Aphasia: Ask to name objects, follow commands, repeat phrases
- If dominant hemisphere (left MCA) - Broca's aphasia (non-fluent) or Wernicke's aphasia (fluent but incomprehensible)
Cranial Nerve Examination:
| Cranial Nerve | Examination | Expected Finding |
|---|---|---|
| CN I (Olfactory) | Ask if smell is intact | Normal |
| CN II (Optic) | Visual acuity, visual fields by confrontation, fundoscopy | Check for papilledema (raised ICP), diabetic/hypertensive retinopathy; hemianopia if PCA/posterior MCA |
| CN III, IV, VI (Oculomotor, Trochlear, Abducens) | Eye movements, pupil size, reaction to light | Normal in MCA stroke usually; abnormal in brainstem stroke |
| CN V (Trigeminal) | Facial sensation, jaw muscles, corneal reflex | Usually normal |
| CN VII (Facial) | KEY FINDING - Raise eyebrows, close eyes tightly, show teeth, puff cheeks | Lower 2/3 of face weakness on contralateral side; UPPER FACE SPARED (forehead sparing) = UMN facial palsy - This is the hallmark UMN vs LMN distinction |
| CN VIII (Vestibulocochlear) | Hearing, Rinne and Weber tests | Normal in MCA stroke |
| CN IX, X (Glossopharyngeal, Vagus) | Uvula, gag reflex, palate movement | Usually normal; abnormal in posterior circulation |
| CN XI (Accessory) | Sternocleidomastoid and trapezius strength | Usually normal |
| CN XII (Hypoglossal) | Tongue protrusion - note if deviated | Tongue deviates toward weak side in UMN; away from lesion |
Key clinical point: Lower half of face paralysis with forehead sparing = Upper Motor Neuron (UMN) facial palsy = lesion is in the contralateral motor cortex (internal capsule, or the cortical representation). This is the classic sign of a contralateral cerebral hemisphere stroke (typically MCA territory). The forehead is spared because it has bilateral cortical representation.This is the opposite of LMN (Bell's palsy) where the entire half of face including forehead is paralyzed.
Motor System Examination:
Write it as follows:
- Bulk: Normal / Wasting - "No significant wasting of muscles noted"
- Tone:
- In acute stroke: tone may be DECREASED (hypotonia/flaccid) initially
- In established/subacute stroke: tone becomes INCREASED (spasticity - clasp-knife type)
- Test all four limbs
- "Tone is decreased in the right upper and lower limbs" (if acute phase)
- Power:
- Grade by MRC scale (0-5)
- Test proximally and distally in all four limbs
- Example: "Power in the right upper limb - shoulder abduction 3/5, elbow flexion 3/5, wrist extension 3/5, grip 3/5. Right lower limb - hip flexion 4/5, knee extension 4/5, ankle dorsiflexion 4/5. Left upper and lower limbs - power 5/5."
- Note: In MCA stroke, face and arm are more affected than leg (face > arm > leg pattern)
- Deep Tendon Reflexes (DTR):
- Acute stroke: reflexes may be DIMINISHED or ABSENT initially
- Later: Reflexes become BRISK (hyperreflexia) with UMN signs
- Test: Biceps (C5,6), Triceps (C7), Supinator (C5,6), Knee (L3,4), Ankle (S1,2)
- Document as: absent (-), diminished (+/-), normal (++), brisk (+++), very brisk (++++) with clonus
- Plantar Response:
- Babinski's sign: UPGOING PLANTAR (extensor plantar) on the affected side = UMN lesion
- This is a critical positive finding in stroke
- Document: "Right plantar response - extensor (Babinski positive); Left plantar response - flexor (normal)"
- Coordination: Finger-nose test, heel-shin test, rapid alternating movements - document even if expected to be normal (to rule out cerebellar involvement)
Sensory System:
- Superficial sensation: Light touch, pain (pinprick) - may have contralateral hemisensory loss in MCA territory stroke
- Deep sensation: Joint position sense, vibration (128 Hz tuning fork)
- Cortical sensations: Two-point discrimination, graphesthesia - impaired in parietal lobe involvement
- Document as: "Diminished sensation on right side of face and right upper limb to light touch and pinprick"
Cerebellar Signs:
- Romberg test, gait (if possible), nystagmus
- Typically normal in MCA stroke; positive in posterior circulation stroke
Meningeal Signs:
- Neck stiffness, Kernig's sign, Brudzinski's sign
- Positive in SAH or meningitis - expected NEGATIVE here, but must be documented
B. CARDIOVASCULAR EXAMINATION
- Inspection: JVP, apex beat position
- Palpation: Apex beat, thrills
- Auscultation: Heart sounds, any murmurs (mitral stenosis - source of AF and emboli; aortic stenosis)
- Auscultate for carotid bruits - atherosclerotic carotid stenosis is a major cause of stroke in diabetic, hypertensive patients
- "S1 S2 heard normally, no added sounds or murmurs. Carotid bruit: absent/present."
C. RESPIRATORY EXAMINATION
- Inspection, palpation, percussion, auscultation
- Mainly to rule out aspiration pneumonia (common complication of stroke due to dysphagia/dysarthria)
- "Air entry equal bilaterally, no adventitious sounds"
D. ABDOMINAL EXAMINATION
- Routine inspection, palpation, percussion, auscultation
- Note any hepatosplenomegaly (liver disease - coagulopathy)
- Note bladder distension (urinary retention - common in stroke)
- "Abdomen soft, no organomegaly, bladder not palpable"
E. FUNDOSCOPY (Special Examination - critical in this case)
- Hypertensive retinopathy - expected in 3-year hypertensive (AV nipping, flame hemorrhages, silver/copper wiring, papilledema in malignant hypertension)
- Diabetic retinopathy - expected in 15-year diabetic (microaneurysms, dot-blot hemorrhages, neovascularization)
- Papilledema - raised ICP from massive stroke or hemorrhagic stroke
- Document by Keith-Wagener-Barker grading for hypertensive retinopathy
PROVISIONAL DIAGNOSIS
Acute ischemic stroke - right hemisphere MCA territory (likely cortical branch), presenting as:
- Left-sided UMN facial palsy (lower half)
- Dysarthria
- Wake-up stroke onset
OR if left-sided facial paralysis with right hemisphere: adjust side accordingly based on examination findings.
The lower face paralysis is on the opposite side to the cerebral lesion (contralateral).
DIFFERENTIALS TO RULE OUT
- Hemorrhagic stroke (ICH/SAH) - Rule out with urgent non-contrast CT brain (most important)
- Todd's paralysis - Post-ictal weakness after a seizure; rule out by history (no witnessed seizure)
- Hypoglycemia - Immediate bedside blood glucose; treatable and completely reversible
- Hypertensive encephalopathy - Very high BP with encephalopathy, usually no focal deficits
- Migraine with aura (hemiplegic migraine) - Unusual in 65-year-old; no headache here
- Bell's palsy (LMN) - But forehead is SPARED here = UMN, not Bell's palsy; forehead involvement = Bell's palsy
- Brain tumor / space-occupying lesion - Gradual onset usually; CT/MRI differentiates
BEDSIDE IMMEDIATE INVESTIGATIONS
- Blood glucose - stat (rule out hypoglycemia)
- ECG - rule out AF (cardioembolic source), acute MI
- Non-contrast CT brain - emergent (distinguish ischemic from hemorrhagic stroke)
- SpO2, BP in both arms
- CBC, blood glucose, electrolytes, renal function, coagulation (PT/INR, APTT) - for tPA eligibility
- HbA1c, lipid profile - after stabilization
SOURCES
- Washington Manual of Medical Therapeutics (Stroke: History, Physical Examination, Diagnosis sections)
- Schwartz's Principles of Surgery, 11th Ed. (Common Types of Strokes - MCA territory)
- Harrison's Principles of Internal Medicine 22E (Stroke Syndromes - MCA occlusion, anterior circulation)
- Adams and Victor's Principles of Neurology, 12th Ed. (Differentiation of Stroke From Other Neurologic Illnesses)
- Gray's Anatomy for Students (Clinical - suspected stroke management pathway)
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