Limb Weakness

A 62-year- old Malay chronic ex-smoker with underlying hypertension, type II diabetes mellitus and dyslipidemia for the past 8 years was brought in due to left-sided body weakness. It was of sudden onset and associated with profuse sweating followed by loss of consciousness for approximately 10 minutes. He did not have headache, dyspnoea, chest pain, fever or any signs suggestive of seizures. Prior the episode, he had been experiencing dizziness on awakening and blurring of vision.

His current list of medications included tablet perindopril 8 mg OD, tablet amlodipine 10 mg OD, tablet metformin/glibenclamide 500 mg/5 mg BD, subcutaneous (s/c) insulatard basal 10 units ON, tablet simvastatin 20 mg ON and tablet aspirin 100 mg OD.

On examination, he was well built was lying supine on the bed. He was drowsy with Glasgow coma scale (GCS) of 11/15 (E3V2M6). Left-sided facial asymmetry with drooping of the edge of the mouth towards the left side and slurring of speech were noted. He was hypertensive with blood pressure (BP) of 174/90 mmHg and was hyperglycemic with capillary blood glucose measuring 10.2 mmol/L. Physical examination further revealed flaccid muscle tone and reduced power of both upper and lower limbs over the left side, with Medical Research Council (MRC) grade of 2/5. Extensor plantar response was positive on the left side.

On day 3 of admission, neurological examination showed rigid muscle tones with MRC of 3/5 and brisk reflexes over the left upper and lower limbs. On day 5 of admission, he complained of neck pain and there was presence of neck stiffness on examination.

  1. What is the reason for his limb weakness on the left side of the body?
  2. What does the loss of consciousness at the onset of his illness suggest?
  3. What is the cause of the facial asymmetry in him?
  4. What is the reason for his "slurring of speech"?
  5. How do you explain the differences in neurological findings at admission and after 3 days?
  6. What could be a possible reason for his neck pain and neck stiffness?
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