CASE 83: WEAKNESS
History
A 76-year-old woman presents to the emergency department complaining of an episode of
weakness in her right arm and leg. She was sitting down with her husband when the weak-
ness came on and her husband noticed that she slurred her speech. All of the symptoms
resolved within 10 min. Her husband has noticed two to three episodes of slurred speech last-
ing a few minutes over the last 6 months but had thought nothing of it. Two months earlier
she had a sensation of darkness coming down over her left eye and lasting for a few minutes.
She has had type 2 diabetes mellitus for 6 years, controlled on diet. She is hypertensive and
suffered a myocardial infarction 3 years previously. She smokes about 10 cigarettes per day
and drinks alcohol rarely. Her only medication is enalapril for her blood pressure.
Examination
She looks frail. Her pulse rate is 88/min irregular and blood pressure 172/94 mmHg. The apex
beat is displaced to the sixth intercostal space, mid-axillary line. Her heart sounds are normal
and a grade 3/6 pansystolic murmur is audible. A soft bruit is audible on auscultation over
the left carotid artery. Her dorsalis pedis pulses are not palpable bilaterally and her posterior
tibial is weak on the left and absent on the right. Examination of her chest and abdomen is
normal. Neurological examination demonstrates normal tone, power and reflexes. There is no
sensory loss. Funduscopy is normal.
NormalHaemoglobin 13.7 g/dL 11.7–15.7 g/dL
Mean corpuscular volume (MCV) 86 fL 80–99 fL
White cell count 7.4% 109 /L 3.5–11.0% 109 /L
Platelets 242 % 109 /L 150–440% 109 /L
Sodium 137 mmol/L 135–145 mmol/L
Potassium 3.9 mmol/L 3.5–5.0 mmol/L
Urea 6.7 mmol/L 2.5–6.7 mmol/L
Creatinine 86 &mol/L 70–120&mol/L
Glucose 5.8 mmol/L 4.0–6.0 mmol/L
Haemoglobin A1c(HbA1c) 7.6 per cent !7 per centChest X-ray: normal
Electrocardiogram (ECG): atrial fibrillationINVESTIGATIONS
Questions
- What is the diagnosis?
- How would you manage this patient?