Physician's Assistant

Refined clerking Mon 09 February 2026 18:49

Last Modified: 8 weeks ago

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Medical ST5 Miller Clerking
09/02/2026 18:45

Presenting Complaint:
Progressive weakness and falls

History of Presenting Complaint:
7 weeks ago stopped nefopam which had been effective for back pain. 4.5 weeks ago sustained head injury at work whilst bending down, followed by headaches and generalised weakness. Developed "full body weakness" 4 weeks ago. Symptoms have progressively worsened over past week, particularly affecting left side. Now reports complete loss of strength in left leg with episodes of leg "giving way" causing falls. Right leg also affected but less severely. Unable to weight bear on left leg which "quivers and dies" when attempting to stand.

Developed new incontinence starting last Tuesday. Reports intermittent jerking movements of hands and legs with electric shock-like pains running through body. Swallowing difficulties reported. Visual symptoms include intermittent blurry vision affecting one eye. Balance problems and altered auditory perception.

Patient lives with parents and brother. Works at hotel. Very concerned about safety at home due to frequent falls.

Significant background of chronic bilateral ptosis since childhood, memory difficulties, and complex PTSD. Currently under neurology investigation with normal tests to date including EEG, EMG, brain MRI, whole spine MRI, and various blood tests.

Past Medical History:
• Complex PTSD
• Chronic bilateral ptosis (since childhood)
• Memory and cognitive problems
• Mixed anxiety and depressive disorder
• Migraine
• Convergence insufficiency
• Subclinical hypothyroidism
• High hypermetropia
• Irritable bowel syndrome
• Gastritis (2023)
• Testicular pain (2023)
• Recent dental extractions (January 2026)

Drug History:
• Amitriptyline 20mg PO OD
• Omeprazole 20mg PO OD
• Famotidine (dose not specified)
• Atogepant (dose not specified)

Recently Stopped Medications:
• Nefepam - stopped 7 weeks ago (had been taking for back pain)
• Tramadol - recent acute prescription
• Naproxen - recent acute prescription

Allergy History:
Not specifically mentioned

Social History:
Lives with parents and brother at home
Works at hotel doing general kitchen work
Mother works as nurse at this hospital
Mobility severely impaired - using walls for support, frequent falls
Concerned about safety at home alone

On Examination:
General Appearance: Alert, anxious about mobility
Able to mobilise very short distances but appears to be struggling. But also managed to walk here?
• Neurological: Coordination difficulties particularly affecting left side. Left arm held in fixed position but able to raise wrist with no wrist drop. Able to keep elbow flexed in fixed position. Power 5/5 on left side, reduced range of active movement. Actively limited movement but passively able to move throughout range. Hoover's sign positive. Right side power good but some discoordination. Reduced sensation on left side with pins and needles. Reduced vibration sense. Gait very unsteady, dragging left leg, requiring support.
• Other systems: Not fully documented

Investigations:
• FBC Normal
• LFTsNormal
• CRP 1
• U&Es Normal
• MRI Pelvis (03/02/2026): Normal appearances
• Previous extensive neurology investigations: EEG, EMG, brain MRI, whole spine MRI, serum CK, lactate, MuSK and AChR antibodies - all normal or negative

Impression:
Worsening of chronic neurological symptoms being investigated by neurology team with no organic cause found so far. 
No objective evidence of left sided weakness despite symptoms of left sided weakness. Patient concerned about being at home and falling.

Management Plan:
1. Admit for observation and safety given fall risk and patient concerns
2. IV fluids for possible dehydration
3. Neurology review
4. Acute Medical Unit bed
5. Encourage mobilisation and physiotherapy input
6. Neuropsychiatry follow-up appointment 25/02/2026

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Refined clerking Mon 09 February 2026 18:49

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