Physician's Assistant

Refined clerking Mon 22 September 2025 00:18

Last Modified: 28 weeks ago

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Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Headache and neurological symptoms

History of Presenting Complaint:
Three days of severe splitting frontal headache. Today at 3pm developed dizziness, continuing headache and "slurred speech" whilst at residential care home. Speech symptoms had resolved by the time ambulance crew arrived. However, ambulance crew identified left sided leaning with left sided visual disturbance and left visual field defect.

Well recently otherwise with no other complaints.

Past Medical History:
• Osteoporosis
• Congestive heart failure
• CKD Stage 4
• Atrial fibrillation
• Acute NSTEMI (2021)
• Pacemaker in situ (2016) for complete heart block
• Osteoarthritis
• Hypertension

Drug History:
• Mirtazapine 50mg PO ON
• Furosemide 40mg PO OM
• Laxido 1 sachet PO OD

Allergy History:
NKDA

Social History:
Lives in residential care home. Independent in toileting and eating. Has been recently rehabilitating walking up to 50 metres with zimmer frame.

On Examination:
Alert GCS 15
• Cardiovascular: Normal heart sounds, chronic venous changes in legs without evidence of infection or cellulitis
• Respiratory: Normal respiratory sounds
• Abdomen: Soft, non-tender
• Neurological: No dysarthria or aphasia present. Good power in all four limbs. Flattening of left nasolabial fold but no significant facial droop, forehead spared. Patient leans to the left but no clear inattention. Visual fields difficult to assess due to patient unable to open eyes widely, but no clear lateralising visual field deficit identified. 
• Other: Dressed wound to right arm

Investigations:
• Potassium (July): 4.9
• Sodium (July): 138
• ALP: 238 (previously 175)
• CRP: 13
• Urea: 17.8
• FBC: 122
• Blood gas: No acidosis
• CT Head: No acute intracranial haemorrhage or ischaemia, age-related cerebral atrophy and bilateral oligodendrogliosis, no skull fracture
• ECG: Atrial flutter with demand pacing, rate 85

Impression:
Possible small lacunar infarct with rapidly resolving symptoms

Management Plan:
1. Overnight observation and monitoring
2. Consider discharge to residential home in morning if stable
3. Patient not candidate for revascularisation therapy given age and functional baseline
4. Aspirin
5. TEP previously discussed. WBC

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Summary:

Investigations:

Refined clerking Mon 22 September 2025 00:18

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