Physician's Assistant

Refined clerking Fri 20 February 2026 19:54

Last Modified: 45 days ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Recurrent headache with neurological symptoms

History of Presenting Complaint:
Patient initially presented in August 2025 with two episodes of expressive dysphasia and right-sided weakness. He experienced severe headache at the time and visual disturbance in his left eye. All symptoms had resolved by time of discharge. He underwent CT and MRI head which demonstrated mild small vessel disease but no acute ischaemia.

He re-presented in September 2025 as a stroke call with right-sided facial droop and expressive dysphasia identical to August admission. NIHSS was 3 on arrival, falling to 0 within one hour with complete resolution of symptoms. This was followed by headache matching previous presentation. Discussed with Dr France at that time who felt this was atypical migraine rather than TIA given third occurrence with identical symptoms.

He presented again on 18th February 2026 (two days prior to current attendance) with identical symptoms. Seen by medical registrar on arrival. CT head showed moderate background small vessel ischaemic changes but no acute infarct, no intra or extra-axial haemorrhage, no acute abnormality. Blood tests on 18th were normal.

Presents today with further episode. Describes severe left-sided posterior headache starting after a period of aura. Subsequently develops transient neurological symptoms including speech disturbance (both dysarthria and dysphasia) and limb weakness. He reports knowing what he wants to say but words won't come out. His wife reports he drops things, his eyes look dazed, and he becomes agitated during episodes. He finds the unpredictability of attacks distressing as they can occur days apart or weeks apart with no clear pattern. Symptoms had largely resolved at time of assessment with only residual mild headache remaining. Paracetamol provides inadequate relief.

Past Medical History:
• Migraine with aura - diagnosed September 2025
• Small vessel disease - noted on MRI head August 2025
• Mild carotid stenosis - noted on neck imaging 2025, no treatment required

Drug History:
None documented in current presentation

Recently Stopped Medications:
None mentioned

Allergy History:
Not documented

Social History:
Lives with wife. Married 63 years. Independent in activities of daily living between episodes. No smoking or alcohol history documented. Functional status good when asymptomatic.

On Examination:
General Appearance: Alert, comfortable, neurological symptoms resolved
Observations: Not documented
• Cardiovascular: Heart sounds normal
• Respiratory: Chest clear
• Abdomen: Soft and non-tender
• Neurological: No residual neurological symptoms. No focal neurology identified
• Other: No peripheral oedema

Investigations:
• Full Blood Count (18/02/26): Normal
• Blood tests (18/02/26): All normal
• CT Head (18/02/26): Moderate background small vessel ischaemic changes, no acute infarct, no intra or extra-axial haemorrhage, no acute abnormality
• CT Head (August 2025): Mild small vessel disease, no acute ischaemia
• MRI Head (August 2025): Mild small vessel disease, no acute ischaemia
• Carotid imaging (2025): Mild stenosis, no treatment required
• Blood tests (20/02/26): Awaited

Impression:
Migraine with aura
Differential Diagnoses: TIA excluded based on complete symptom resolution, pattern of recurrence, and normal imaging. Stroke very unlikely given rapid resolution and headache predominance.

Management Plan:
1. Reassurance provided to patient and wife regarding diagnosis
2. Prescription issued for Sumatriptan 50mg PO to be used as abortive therapy during aura phase
3. Safety netting advice provided
4. Discharge home with GP follow-up
5. Patient education on recognising aura and early use of Sumatriptan
6. Request GP to add Sumatriptan to repeat prescriptions
7. No admission required - discharged from Emergency Department
8. Advised to re-attend if symptoms change in character or fail to resolve

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Summary:

Investigations:

Tasks

Feedback

• Excellent patient-centred approach with clear, jargon-free explanations that reassured an anxious couple
• Strong empathy demonstrated by acknowledging the frightening nature of symptoms and validating the wife's concerns about her husband's agitation
• Good use of previous investigation results to provide reassurance and avoid unnecessary repeat testing
• Appropriate safety-netting by explaining when symptoms would be concerning (if they didn't resolve)
• Could have documented medication allergy status more explicitly - important for prescribing safety
• Could have explored functional impact more systematically (driving status, falls risk during episodes, work impact)
• Observations not documented - would be helpful baseline given cardiovascular differential
• Consider documenting specific questions about visual aura characteristics, duration of aura phase, and post-headache symptoms for future migraine management
• Excellent rapport building with personal conversation while maintaining professionalism