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A state of confusion
  1. N Sofat,
  2. C S Higgens
  1. Northwick Park and St Marks' Hospital, Watford Road, Harrow, Middlesex HA1 3UJ, UK
  1. Dr Sofat sofat{at}nsofat.freeserve.co.uk

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Answers on p 677.

A 66 year old right handed man was admitted via the accident and emergency department with confusion and weakness. His wife gave most of the history, saying he had not been able to express himself clearly for the last day and looked weak. He had no history of ischaemic heart disease, hypertension, hypercholesterolaemia, diabetes mellitus, or previous strokes. He smoked 10 cigarettes a day and drank alcohol only socially. He had been diagnosed with rheumatoid arthritis 20 years before. His drug history included diclofenac. On examination, the admitting doctor found that he had an expressive dysphasia and a right hemiparesis. He had a blood pressure of 140/70 mm Hg, pulse 80 beats/min and regular, both first and second heart sounds present with no added sounds and his chest was clear. His abdomen was soft and non-tender with no organomegaly. He had bilateral metacarpophalangeal joint swelling in his hands with ulnar deviation. On further neurological assessment he had an upper motor neurone right facial nerve palsy and the rest of his cranial nerves were normal. In his limbs, in addition to the right hemiparesis, he also had an ulnar nerve palsy in his left hand.

The patient was diagnosed as having had an acute stroke. Computed tomography the same day showed areas of hypodensity consistent with fresh infarctions in the temporal lobes bilaterally and also in the left frontoparietal lobe. He was started on 300 mg aspirin daily. His plasma lipids and glucose were found to be normal. Doppler examination of his carotid arteries and cardiac echocardiogram were also normal. He was transferred to the neurorehabilitation unit. Five days after his admission, he was noted to have a lesion in his left eye as illustrated in fig 1. He was also seen to have a lesion over his left lateral malleolus, shown in fig 2, which was very painful.

Figure 1

Illustration of patient's eye as seen a few days after admission (reproduced with patient's permission).

Figure 2

Photograph of the patient's lower leg (reproduced with patient's permission).

Questions

(1)
What is illustrated in fig 1?
(2)
What is the skin lesion illustrated in fig 2?
(3)
What is the unifying diagnosis?
(4)
What treatment would you now offer the patient?
(5)
What is his prognosis?

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