Case History/ Examination

A 20-year-old male non-smoker and non-alcohol consumer came to the emergency department with chief complaints of left-sided weakness, slurred speech and right-sided facial deviation for six days. The patient was well six days back when he had a headache in the right temporal region associated with nausea. He had a headache in the right-sided temporal region for six days, which is sharp pain. He gave a 6 out of 10 on the pain analogue scale, which was continuous when he woke up in the morning and wanted to go to the bathroom; however, he could not walk properly. After 1 hour, he fell and could not balance himself on the passage. He first developed weakness in the left lower limb, followed by weakness in the left arm. He also developed slurring of speech, which was understandable, along with facial deviation without drooling of saliva. He has a significant history of pulmonary valve stenosis 12 years back with balloon valvuloplasty. There was no significant drug history, family history or substance abuse history.  The patient was conscious and oriented to time, place, and person on examination, and his higher mental function was intact. His blood pressure was 110/70 mmHg, pulse was 89 beats per minute, respiratory rate was 20 per minute, and SPO2 was 97% on the right hand. A neurological examination was done, where Bulk was normal bilaterally, and tone was intact on the upper and lower limbs. Power on the right side was intact, whereas power on the left upper and lower limbs was 4 out of 5. On cranial nerve examination, face deviation was found, and frowning was absent on the left side. His sensory examination revealed decreased sensation to vibration till the umbilicus, whereas position sensation was intact. Waddling gait was present, and Gower’s sign was positive. Babinski on the bilateral limbs was down going, and cerebellar examination was normal; however, nystagmus was present. There was no sign of meningeal irritation. During the cardiovascular examination, S1 and S2 heart sounds were heard, and they were expected.