Physician's Assistant

Refined clerking Wed 01 April 2026 10:05

Last Modified: 5 days ago

MRN:

Content:

Presenting Complaint:
Worsening weakness

History of Presenting Complaint:
Presented with a subjective deterioration in mobility and weakness overnight, on a background of an acute lacunar stroke in the basal ganglia in August with residual left-sided weakness, particularly affecting the leg and hand. He reported that he had been improving with rehabilitation and had been able to walk, type, and play piano exercises with his left hand, but over the past few days had felt generally unwell and a little more wobbly. This morning he woke with marked difficulty standing and walking, and felt weaker on both sides, which felt different from his previous stroke symptoms. He denied new speech disturbance, new visual loss, or focal arm weakness. He described mild coryzal symptoms with cough, sputum, and feeling snotty. He also reported urinary frequency/dribbling over the past few days. Home blood glucose this morning was 15 mmol/L and on arrival was approximately 16 to 17 mmol/L. He felt his symptoms were similar to previous episodes when he had infection-associated hyperglycaemia.

Past Medical History:
• Acute lacunar stroke, August 2025, with residual left-sided weakness
• Diabetes mellitus, likely insulin-dependent
• Diabetic eye disease/macular changes
• Cataracts
• Sepsis with renal/urinary source, 2018
• Previous groin/abdominal cyst excision

Drug History:
• Insulin degludec (Tresiba) 38 units SC OD
• Dapagliflozin 10mg PO OD
• Clopidogrel 75mg PO OD
• Metformin PO
• Statin PO nocte

Allergy History:
NKDA

Social History:
Lives in Darlington.
Never smoker.
Minimal alcohol intake.
Previously taught data science to master's students at Exeter University.
Functionally independent but with residual stroke-related left-sided weakness; mobilising better prior to this episode.

On Examination:
Alert and able to give a coherent history.
Neurological: Speech normal. Upper limb power and hand grip symmetric on examination. Able to raise arms against resistance. Gait not formally assessed in detail, but observed walking into the room. No new focal upper limb deficit elicited.
Cardiovascular: Normal on brief examination.
Respiratory: No respiratory distress noted. Mild upper respiratory tract symptoms by history.
Abdomen: Soft and non-tender.

Investigations:
• Blood glucose: 16 to 17 mmol/L
• Urinalysis: to be sent for dipstick and laboratory testing
• Viral screen: requested
• Chest X-ray: requested
• Blood tests: requested

Impression:
Exacerbation of old stroke symptoms in the context of intercurrent illness and hyperglycaemia, most likely viral respiratory tract infection. 
No evidence from the history or examination of a new acute stroke.

Management Plan:
1. Check urinalysis and send urine for laboratory testing.
2. Send blood tests including infection screen.
3. Request viral screen.
4. Arrange chest X-ray to assess for chest infection.
5. Give insulin to reduce hyperglycaemia.
6. Review results and reassess clinically for alternative causes of symptom exacerbation.

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Summary:

Investigations:

Refined clerking Wed 01 April 2026 10:05

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