Physician's Assistant

Patient Details

Refined clerking (8 weeks ago 15:14)

Refined clerking Mon 09 February 2026 15:14

Last Modified: 8 weeks ago

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Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Left sided weakness

History of Presenting Complaint:
Presents with left sided weakness. Clinical assessment suggests possible acute ischaemic stroke or infective process contributing to neurological symptoms. Chronological details of onset and progression require further clarification.

Past Medical History:
• Unknown

Drug History:
• Unknown

Allergy History:
• Unknown

Social History:
• Unknown

On Examination:
• General examination findings not documented

Investigations:
• Calcium: 2.74 (corrected)
• CRP: 6
• Phosphate: Normal
• Magnesium: Normal
• CT Head: No acute intracranial abnormality, age related cerebral atrophic changes with severe small vessel disease (suboptimal patient positioning and minor motion artefacts)
• WBC: 14.7 (Neutrophils 9, Lymphocytes 4.25, Monocytes 0.94)
• INR: 0.9
• LFTs: Normal
• Troponin: 83 (requires repeat)
• Creatinine: 116 (baseline 85)
• Sodium: 148 (previously 146)
• Glucose: Normal
• Cholesterol: 7.4
• Urea: 19.4 (previously 5.8)
• AST: Normal
• Venous Blood Gas: pH 7.37, Potassium 3.4, Base excess 1.7
• Urine MC&S (December 2025): E. coli resistant to amoxicillin, susceptible to co-amoxiclav

Impression:
87-year-old lady with left sided weakness
Differential Diagnoses: Infection vs acute ischaemic stroke

Management Plan:
1. Repeat troponin measurement
2. Monitor neurological observations
3. Consider antibiotic treatment based on urine culture sensitivities
4. Address dehydration and electrolyte imbalances
5. Stroke team assessment if clinical suspicion remains
6. Medical ward admission
7. Escalation plan to be discussed

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Refined clerking Mon 09 February 2026 15:14

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