# Sudden right-sided weakness and loss of speech, a 58-year-old: a case to work up

> A neurology emergency case for medical students: a 58-year-old whose right hand dropped a cup and whose speech went an hour ago. Time last seen well, mimics to exclude, the first tests and the differential.

- Neurology · Intermediate · about 20 minutes
- Web page: https://www.medikarya.in/case-studies/58-year-old-woman-whose-right-side-suddenly-went-weak
- Work up this patient: https://www.medikarya.in/case-studies/58-year-old-woman-whose-right-side-suddenly-went-weak

## How the patient presents

Her son says she was eating breakfast when her right hand dropped the cup and she could not get her words out. That was a little over an hour ago. He tells you what he saw.

## Why sudden one-sided weakness matters

In sudden weakness, time lost is brain lost. Recognise a stroke quickly, exclude mimics such as a low glucose, and get a brain scan fast, because the treatments depend on timing and on whether there is bleeding.

## What to ask in the history

- Exactly when she was last seen well, from the witness
- What happened: face, arm, leg, speech, vision
- Headache, vomiting, a seizure at the start
- Previous stroke or mini-stroke
- Irregular heartbeat, blood pressure, diabetes, smoking
- Blood thinners and antiplatelet medicines
- Recent surgery, bleeding or head injury
- How she managed day to day before

## Red flags

- Drowsiness
- Severe headache
- Taking blood thinners
- Very high blood pressure
- Symptoms getting worse
- Trouble swallowing

## What to examine

- Airway, breathing, circulation; glucose; observations
- Conscious level
- Face, arm and leg power; speech and language; visual fields; eye movements; sensation; neglect
- A structured stroke scale
- Pulse rhythm
- A swallow screen before anything by mouth

## First investigations

- Capillary glucose first
- Urgent CT of the brain, with angiography where available
- ECG
- Full blood count, clotting, electrolytes, kidney function
- Later: cholesterol, HbA1c, echocardiogram, carotid imaging

## Differential diagnosis of sudden one-sided weakness

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

### Stroke

- Ischaemic stroke
- Haemorrhagic stroke

### Mimics

- Hypoglycaemia
- Weakness after a seizure
- Migraine with aura
- Brain tumour
- Subdural haematoma
- Functional disorder

### Infection

- Brain abscess
- Encephalitis

## Common mistakes

- Not pinning down when she was last seen well.
- Giving food, drink or tablets by mouth before a swallow check.
- Lowering the blood pressure without a clear reason.

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A study guide for medical students, not medical advice. Follow your institution's protocols in practice.