Physician's Assistant

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Medical ST5 Miller Clerking
Date: 26/02/2027 23:55

Presenting Complaint:
Weakness, nausea, vomiting and diarrhoea

History of Presenting Complaint:
A 59-year-old male with a background of fibrillary astrocytoma (excised 2014) presented to the Emergency Department via ambulance at 19:55. He had been feeling generally unwell for the preceding three days with nausea, vomiting, and diarrhoea. He had been febrile at home and globally weak. The ambulance crew noted predominantly left-sided weakness in the context of his known history of brain malignancy and pre-alerted for a stroke.

On assessment, symptoms were fluctuant; he was able to perform finger-to-nose testing better than sustained arm elevation, suggesting a functional or metabolic overlay rather than an acute focal neurological deficit. Time of symptom onset was approximately 06:00 on the day of presentation as reported by the ambulance crew. No collateral history was available.

Past Medical History:
• Fibrillary astrocytoma - diagnosed 2013, excised 2014
• Low-grade glioma (likely the same lesion as above)
• Epilepsy
• Non-alcoholic fatty liver disease
• Oesophageal reflux disease
• Previous neurosurgery (2014)

Drug History:
• Levothyroxine sodium 25mcg PO 5 days per week
• Hydrocortisone 10mg PO with breakfast; 5mg PO with lunch; 5mg PO with dinner
• Sodium valproate (Epilim Chrono) 800mg PO BD
• Omeprazole 20mg PO OD
• Levetiracetam (Keppra) 1.5g PO BD
• Zonisamide 250mg PO BD (as 50mg capsules)

Allergy History:
Not documented.

Social History:
Not documented.

On Examination:
General Appearance: Unwell, globally weak, with fluctuating left-sided deficit. Facial droop noted on arrival, with some improvement observed during assessment.

• Neurological: NIHSS score 8/14. Predominantly left-sided weakness. Fluctuating power; finger-to-nose testing better preserved than sustained limb elevation. Facial droop, improving.
• Respiratory: Auscultation performed; findings not documented. Chest X-ray requested.
• Other: No IV access on arrival; cannula sited during assessment.

Investigations:
• Hb: 188 (elevated, consistent with significant dehydration)
• INR: Normal
• Creatinine: 121 (baseline 97, consistent with pre-AKI)
• Urea: 6.8
• ALT: 42 (previously 40)
• AST: 28
• Electrolytes: Normal
• Glucose: Normal
• Cholesterol: 6.2 (non-fasting sample)
• CRP: 29 (no previous result for comparison)
• Venous blood gas: pH 7.34, lactate 1.6
• CT Head (26/02/2027): Large area of vasogenic oedema. Radiologist reports similar extent and distribution to previous MRI, previously attributed to radiation-induced changes within the deep white matter. No appreciable underlying mass lesion. Very little interval change since previous surgery. No new acute intracranial pathology identified.

Impression:
Stroke mimic with global but predominantly left-sided weakness, most likely secondary to infective gastroenteritis causing dehydration and a low-flow state in the context of previous neurosurgery and pre-existing structural brain changes.

Differential Diagnoses:
• Acute ischaemic stroke (less likely given fluctuating symptoms and stable CT appearances)
• Recurrence of brain metastasis / low-grade glioma (less likely given no interval change on CT)

Secondary Issues:
• Pre-AKI (creatinine 121, baseline 97) secondary to dehydration
• Adrenal insufficiency on background steroid replacement therapy

Management Plan:
1. IV fluid resuscitation; strict input/output monitoring.
2. Daily U&E monitoring.
3. Chest X-ray to exclude pneumonia; urine dipstick/MC&S to exclude urinary tract infection.
4. No role for antimicrobials at this stage; supportive care.
5. Patient counselled: CT head appearances stable and reassuring; likely stroke mimic precipitated by gastroenteritis in the context of prior neurosurgery causing increased susceptibility to left-sided weakness when systemically unwell.
6. Aim for discharge once clinically improved.
7. Treatment escalation plan (TEP) to be completed; no collateral available at time of clerking.
8. Medical bed for ongoing monitoring and IV fluid management.

Summary:

Investigations:

Refined clerking Fri 27 February 2026 00:18

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