Authors: Ayisha M A Shaikh, Priyadarshini Marathe / Editor: Nick Tilbury / Reviewer: Ayisha M A Shaikh / Codes: CC7, NeuP8, SLO3 / Published: 28/03/2023

It is a beautiful Sunday morning and Mr. and Mrs. Smith are celebrating their 40th wedding anniversary. They are having breakfast when Mrs. Smith screams with pain and drops her coffee mug on the floor. Mr. Smith immediately calls for an ambulance.

The pre-alert from paramedics is of a “Stroke in the window for thrombolysis”. The paramedics report that en-route her vitals were normal but she had opened her bowels in the ambulance without warning.

Mrs. Smith reports that she had had a sudden onset of very severe, sharp lower back pain, which had radiated to her abdomen. The pain reduced within a few minutes but she still has a dull headache, blurred vision and mild left arm weakness.

She has a past medical history of ulcerative colitis. They have been isolating at home during the lockdown, have had no visitors for 8 weeks and have both been well otherwise.

Mrs. Smith is drowsy but following commands. On examination, her heart rate is 40 beats/min, blood pressure in the right arm is 100/46mmHg and 120/50mmHg in the left arm, respiratory rate is 30/min, oxygen saturation is 90% on room air and increases to 96% on 4 liters of O2. Auscultation reveals a diastolic murmur, there is good air entry on both lungs and her abdomen is soft and not tender. Her femoral and radial pulses are present but reduced on both sides. Her left upper limb is slightly weak and pupils are equal in size, reacting normally to light.

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