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Patient Details

Refined clerking (5 days ago 19:16)

Refined clerking Wed 01 April 2026 19:16

Last Modified: 5 days ago

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Medical ST5 Miller
18:30
01/04/2026

Presenting Complaint:
Left-sided weakness and facial droop

History of Presenting Complaint:
30-year-old man with a background of migraine and depression who presented with intermittent left-sided facial and arm symptoms. Over the last year he has experienced episodic electric, numb sensations, previously occurring only every few months, but over recent weeks they have become more frequent. About 3 weeks ago he was started on amitriptyline for worsening migraines. He was also taking mirtazapine, and there was concern about interaction with triptans and sedation.

On Sunday night he developed "zaps" down the right side of his face and a restless right leg. He was then seen by his GP on Monday and mirtazapine was stopped because of blurred vision, facial pains, restless legs and marked tiredness. The following day he developed aura symptoms lasting around 5 hours without headache, together with dizziness and vague chest discomfort, which he felt may have been stress-related. Since then he has had ongoing heaviness and intermittent tingling/numbness, predominantly on the left side, with some subjective weakness in the left arm and left face. He reported that the symptoms had been present since waking that morning and had fluctuated, but had not fully resolved.

He described difficulty getting his words out at times, but no clear dysarthria. He felt his usual migraine aura symptoms had become more intense recently, and he had not used sumatriptan during this episode as it had been stopped when mirtazapine was started. He denied fever, weight loss or night sweats.

Collateral history from his mother was concerning for possible facial droop. He also reported significant psychosocial stress at home, poor energy, and being largely bed bound. He is hoping to move to a ground-floor flat and anticipates carers after his wife's surgery.

Past Medical History:
• Depression
• Migraine
• Labyrinthine disorder, seen in vestibular clinic
• Post-traumatic stress disorder
• Chronic alcohol dependence
• Fibromyalgia
• Tietze's disease
• Metabolic-associated fatty liver disease
• Somatoform pain disorder with depressed mood and anxiety
• Abdominal pain with right upper quadrant pain post-prandial; HIDA scan abnormal and awaiting MRCP after hepatobiliary MDT review

Drug History:
• Amitriptyline
• Mirtazapine
• Sumatriptan
• Omeprazole
• Codeine

Recently Stopped Medications:
• Mirtazapine - stopped by GP due to blurred vision, restless legs, facial pains and sedation

Social History:
Lives with wife and 2 children aged 4 and 2. Wife has a medical problem/tumour and is due to have surgery.
Currently not working.
Mobilises poorly at present, largely bed bound and using a wheelchair; also has a stick at home.
Planned move to a ground-floor flat with carers following wife's surgery.

On Examination:
Alert and able to engage in conversation.
• Cardiovascular: Normal examination.
• Respiratory: Normal examination.
• Neurological: Cranial nerves normal. Subjective left-sided facial tingling. Possible mild left facial droop noted transiently during examination, but facial movements were normal throughout most of the consultation and there was no persistent objective facial weakness. Power was 4/5 in the left arm initially, but when distracted/surprised he demonstrated good power throughout. Sensation was largely normal. Tongue movements normal. Coordination normal. Lower limb examination demonstrated similar features as the UL. No clear objective focal neurological deficit.

Investigations:
• U&Es: Normal
• LFTs: Normal apart from ALT 50
• CRP: 3
• AST: Normal
• Urea: Normal
• FBC: MCV 81.6, remainder normal
• Vitamin B12 and folate: Normal
• Nuclear medicine hepatobiliary function scan: Abnormal gallbladder filling with preferential biliary drainage directly into the small bowel
CT Head normal

Impression:
Most likely migraine with aura causing transient left-sided neurological symptoms, likely exacerbated by cessation of sumatriptan and recent medication changes. 
Stroke ruled out given fluctuating symptoms, preserved objective power when distracted, and inconsistent facial findings.

Management Plan:
1. CT head to exclude acute intracranial pathology.
2. Give aspirin 900mg PO if CT head shows no haemorrhage.
3. If CT head is normal, discharge with medical SHO handover.
4. Restart sumatriptan for migraine (pt has supply)
5. Proceed with planned OPT MRI Head

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Refined clerking Wed 01 April 2026 19:16

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