# Brief weakness of the right arm and leg in a 76-year-old: a case to work up

> A neurology case for medical students: a 76-year-old with right arm and leg weakness and slurred speech that went within ten minutes. What to ask, risk, examination, first tests and the differential.

- Neurology · Intermediate · about 20 minutes
- Web page: https://www.medikarya.in/case-studies/76-year-old-woman-with-brief-weakness-of-her-right-arm-and-leg
- Work up this patient: https://www.medikarya.in/case-studies/76-year-old-woman-with-brief-weakness-of-her-right-arm-and-leg

## How the patient presents

A frail 76-year-old woman had weakness of her right arm and leg with slurred speech while sitting with her husband. It all went within ten minutes. She has diabetes, high blood pressure and heart disease, and smokes.

## Why brief one-sided weakness that has recovered matters

Symptoms that come and go can be a warning before a major stroke, and the risk is highest in the first days. Recognise the episode for what it may be, find the likely source, and start prevention the same day.

## What to ask in the history

- Exactly what happened, when, and for how long
- Speech, vision (including loss of vision in one eye), numbness
- Did everything recover completely
- Previous episodes
- Palpitations or a known irregular heartbeat
- Blood pressure, diabetes, heart disease, smoking, cholesterol
- Medicines, especially for diabetes and blood thinning
- Headache, seizure, low glucose
- How she manages at home

## Red flags

- More than one episode
- Symptoms still present now
- An irregular pulse
- Taking blood thinners
- Very high blood pressure

## What to examine

- A full neurological examination
- Pulse rhythm, blood pressure
- Heart murmurs, carotid bruits
- Glucose

## First investigations

- Glucose
- ECG and heart rhythm monitoring
- Full blood count, electrolytes, kidney function, cholesterol, HbA1c
- Brain imaging, MRI where available
- Carotid Doppler
- Echocardiogram if a source in the heart is possible

## Differential diagnosis of brief one-sided weakness that has recovered

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

### Blood supply to the brain

- Transient ischaemic attack from the carotid artery
- From the heart
- Small vessel disease

### Mimics

- Hypoglycaemia
- Focal seizure
- Migraine aura
- Faint
- Subdural haematoma
- Tumour

## Common mistakes

- Sending her home because she is better now.
- Missing an irregular heartbeat.
- Leaving her risk factors to be treated later.

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