Physician's Assistant

Patient Details

Refined clerking (43 days ago 13:26)

Refined clerking Sun 22 February 2026 13:26

Last Modified: 43 days ago

MRN:

Content:

{
  "mrn": "320761",
  "patient_name": "Anthony Domaine",
  "content": "Medical ST5 Miller Clerking\n\nPresenting Complaint:\nVisual disturbance\n\nHistory of Presenting Complaint:\nAt 09:00 this morning, whilst eating breakfast, patient developed sudden onset blurriness and haziness in his left eye with inability to see objects at distance. He describes this as if his eyes are not opening properly to see. Vision has partially improved since onset but remains significantly impaired compared to baseline. His right eye has had no perception of light since 2023 following right central retinal artery occlusion, making preservation of left eye vision critical.\n\nAssociated with the visual changes, he experienced sweating, nausea with several episodes of vomiting, and a sensation of feeling faint. He was unable to stand from his chair at home. He measured his blood pressure which was 150 mmHg systolic (normally 120 mmHg). He developed dull aching pain in the right elbow crease and right shoulder, with associated weakness and heaviness in the right arm which prevented him from lifting it. The weakness has improved over 2-3 hours. He also experienced difficulty remembering how to perform familiar tasks at home and gave incorrect answers to some questions initially.\n\nHe reports ongoing intermittent frontal and periorbital headaches described as pulsating, occurring every few hours, which he has had since investigations began. He also describes occasional lightheadedness when looking up and down, particularly when bending to the fridge, which has been present since his cardiac surgery but has reduced in frequency recently. He denies any classic symptoms of polymyalgia rheumatica such as bilateral shoulder or hip girdle stiffness, though does have chronic shoulder discomfort.\n\nPatient has been under investigation for possible giant cell arteritis following presentation to TIA clinic on 08/01/2026 with two episodes of blurred vision and flashing lights in the left eye. Multiple investigations have been performed but remain inconclusive. Rheumatology recommended initiation of steroids if he presented with further visual disturbances.\n\nPrevious history includes right central retinal artery occlusion in 2023 with complete vision loss in right eye and right afferent pupillary defect. This was felt to represent previous embolic disease.\n\nPast Medical History:\n• Aortic root replacement (January 2022) - for infected aortic root abscess, complicated by post-operative haemorrhage requiring reoperation\n• Previous aortic valve replacement (2017) - mechanical valve\n• Endocarditis (2022) - treated with Meropenem and Teicoplanin\n• Right central retinal artery occlusion (2023) - resulting in no perception of light in right eye, 6/9 vision in left eye\n• TIA (16/12/2025)\n• Previous diagnosis considered: non-diabetic hypoglycaemia\n• Inguinal hernia repair with hydrocele - complicated by nerve damage to right leg\n• Hypothyroidism\n• Benign prostatic hyperplasia\n• Glaucoma - left eye, on regular drops, 6-monthly ophthalmology follow-up\n• Cataract - left eye (small)\n\nDrug History:\n• Warfarin dose adjusted to INR (10mg 5 times weekly, 9mg 2 times weekly)\n• Atorvastatin 40mg PO OD\n• Bisoprolol 2.5mg PO OD\n• Aspirin 75mg PO OD\n• Lansoprazole 30mg PO OD\n• Levothyroxine 125mcg PO OD\n• Pregabalin 50mg PO BD\n• Finasteride 5mg PO OD\n• Frusemide 20mg PO OM\n• Latanoprost eye drops\n\nAllergy History:\nNo known drug allergies\n\nSocial History:\nLives with wife. Independent in activities of daily living. Enjoys gardening. Previously never attended doctor or hospital until recent cardiac issues. Has required multiple hospital appointments and admissions over past month. Non-smoker. Alcohol consumption not documented.\n\nOn Examination:\nAlert, oriented. NIHSS on admission: 6. NIHSS 45 minutes post-admission: 0.\n\nNeurological examination:\n• Cranial nerves: Left homonymous superior quadrantanopia on formal visual field testing (improved from initial examination). Cannot see examiner's finger in superior temporal field on left. Finger counting preserved peripherally on left. Right eye: no perception of light. Right afferent pupillary defect present. Facial movements symmetrical, no facial droop. Voice character altered - slightly husky/croaky quality (noted by wife). No dysarthria or word-finding difficulty on formal testing. Successfully named objects and read text.\n• Motor: Minimal right arm drift initially (resolved on repeat testing). Right arm weakness on admission with difficulty lifting arm (improved significantly over 2-3 hours). Normal tone. Power now 5/5 all limbs on formal testing. Right leg has chronic weakness from previous nerve damage (longstanding, unchanged).\n• Sensory: Reduced sensation right leg compared to left (chronic from previous nerve damage). Facial sensation intact and symmetrical. Upper limbs symmetrical.\n• Coordination: Finger-nose testing accurate bilaterally (patient notes depth perception difficult with monocular vision but no true past-pointing). Clapping and hand movements performed well.\n• Gait: Not formally assessed due to initial inability to mobilise (now resolved).\n\nCardiovascular:\nMetallic aortic valve heard with soft systolic murmur loudest in aortic area on expiration. No peripheral oedema. Single right thumb splinter haemorrhage noted. No other stigmata of endocarditis.\n\nRespiratory:\nChest clear to auscultation bilaterally.\n\nAbdomen:\nSoft, non-tender. No organomegaly.\n\nInvestigations:\n• Venous blood gas: pH 7.48, Sodium 129, Lactate 2.1\n• Temporal artery ultrasound Doppler: Right temporal artery tortuous with mild intimal thickening 1.5mm, patent frontal vessel compressible with mild intimal thickening 0.4mm, normal waveform velocities, no halo or stenosis. Left mild intimal thickening 0.7mm parietal and 0.4mm frontal, normal waveform and velocities.\n• Right temporal artery biopsy: Marked internal thickening, fragmentation of elastic fibres, few lymphocytes present in adventitia, numerous calcifications. Aspects may suggest temporal arteritis but inconclusive.\n• Whole body PET-FDG scan (02/20/2026, reported 02/22/2026): Moderate increased uptake in root of ascending aorta in region of aortic root collection, could be related to ongoing low-grade inflammation. Moderate increased uptake in wall of root of ascending aorta similar to background liver (intermediate grade 2). Low-grade asymmetrical increased uptake in region of fossa of Rosenmüller. Uptake within wall of thoracic and abdominal aorta is low grade.\n• Blood tests (18/02/2026): CRP 2, normal LFTs and FBC\n• Carotid duplex scan (TIA clinic): No evidence of significant stenosis in left internal carotid artery\n• CT head with contrast today: No large vessel occlusion in brain (full report pending)\n• ECG: Pending\n• INR: Pending\n\nImpression:\nRecurrent visual disturbance in only functioning eye in 77-year-old gentleman with multiple investigations for suspected giant cell arteritis (all inconclusive to date).\n\nDifferential Diagnoses:\n1. Giant cell arteritis with evolving left eye involvement - most concerning given history, typical headache pattern, and visual symptoms, despite inconclusive investigations\n2. Thromboembolic event affecting retinal/ophthalmic circulation - given history of right central retinal artery occlusion, mechanical valve, and infected aortic root\n3. Aortic root infection recurrence with embolic phenomena - given PET scan showing uptake in aortic root region\n4. Transient ischaemic attack affecting visual cortex - though rapid improvement atypical\n5. Stroke affecting visual pathways - though NIHSS improvement to 0 makes this less likely\n\nManagement Plan:\n1. Admit to Acute Medical Unit (not stroke ward) for monitoring and treatment\n2. Check INR urgently - if therapeutic (target range for mechanical valve 2.5-3.5), proceed with steroid therapy. If subtherapeutic, consider thromboembolic aetiology and load with aspirin, discuss with ophthalmology\n3. 12-lead ECG\n4. Blood tests including full inflammatory markers panel\n5. Initiate methylprednisolone IV (check local guidelines for dosing in suspected GCA with visual symptoms) given rheumatology recommendation to treat with steroids if further visual symptoms develop\n6. Urgent rheumatology review tomorrow morning for assessment and management plan regarding possible giant cell arteritis\n7. Ophthalmology review for formal assessment of visual fields and fundoscopy\n8. Monitor visual symptoms closely - any deterioration requires immediate senior review\n9. Consider imaging of aortic root if not adequately visualised on CT head (imaging extended to approximately thoracic inlet level but aortic root not fully captured)\n10. Full escalation plan - patient appropriate for CPR, ITU and NIV if required\n11. Ensure warfarin dosing continues as per usual regimen\n12. Patient and wife educated regarding red flag symptoms requiring immediate review: sudden vision loss, severe headache, jaw claudication",
  "summary": "77-year-old gentleman with sudden onset left visual disturbance, right arm weakness (now resolved), and previous right eye blindness, under investigation for possible giant cell arteritis with inconclusive tests. NIHSS improved from 6 to 0 within 45 minutes.",
  "investigations": "Venous blood gas: pH 7.48, Sodium 129, Lactate 2.1. Temporal artery ultrasound Doppler: Bilateral mild intimal thickening, no halo or stenosis. Right temporal artery biopsy: Marked internal thickening, inconclusive for temporal arteritis. PET-FDG scan 20/02/2026: Moderate increased uptake in aortic root region. Blood tests 18/02/2026: CRP 2, normal LFTs and FBC. Carotid duplex: No significant left internal carotid stenosis. CT head with contrast 22/02/2026: No large vessel occlusion.",
  "tasks": [
    {
      "item": "Check INR result urgently",
      "time_frame": "2026-02-22T14:00:00Z",
      "request": "Urgent INR result required for patient Anthony Domaine (MRN 320761) admitted with visual disturbance. Patient on warfarin for mechanical aortic valve. INR result needed to guide management decision between steroid therapy (if therapeutic) versus thromboembolic treatment (if subtherapeutic). Please prioritise - patient has only one functioning eye."
    },
    {
      "item": "Request urgent rheumatology review",
      "time_frame": "2026-02-23T09:00:00Z",
      "request": "Urgent inpatient rheumatology review requested for Anthony Domaine (MRN 320761), 77-year-old male on AMU.\n\nPresenting complaint: Recurrent visual disturbance in only functioning eye (right eye blind from previous CRAO 2023).\n\nHistory: Under investigation for suspected GCA. Multiple inconclusive tests including temporal artery biopsy (showed intimal thickening, fragmentation of elastic fibres, few lymphocytes - inconclusive), temporal artery USS (mild intimal thickening, no halo), PET-CT (moderate uptake in aortic root region). Previous rheumatology letter recommended initiating steroids if further visual symptoms.\n\nToday: Sudden onset left visual blurriness at 09:00, associated with right arm weakness (now resolved), nausea, vomiting. Initial NIHSS 6, improved to 0 within 45 minutes. Persistent left superior quadrantanopia on examination. Patient reports ongoing intermittent frontal/periorbital pulsating headaches.\n\nBackground: Infected aortic root with replacement 2022, mechanical aortic valve 2017, on warfarin.\n\nRequest: Urgent review for assessment and management plan regarding possible GCA. Patient commenced on IV methylprednisolone pending review. Requires definitive diagnosis and long-term management strategy given risk to remaining eye."
    },
    {
      "item": "Request urgent ophthalmology review",
      "time_frame": "2026-02-23T09:00:00Z",
      "request": "Urgent inpatient ophthalmology review requested for Anthony Domaine (MRN 320761), 77-year-old male on AMU.\n\nPresenting complaint: Acute visual disturbance in only functioning eye.\n\nHistory: Right eye - no perception of light since right central retinal artery occlusion 2023, right afferent pupillary defect. Left eye - baseline vision 6/9, known small cataract, on latanoprost for glaucoma, regular 6-monthly ophthalmology follow-up.\n\nToday: Sudden onset left visual blurriness and haziness at 09:00. Describes vision as not clear, difficulty seeing objects at distance. Examination findings: left homonymous superior quadrantanopia on formal visual field testing, finger counting preserved peripherally.\n\nContext: Under investigation for suspected giant cell arteritis (multiple tests inconclusive). CT head today showed no large vessel occlusion. Patient commenced on IV methylprednisolone for presumed GCA given visual symptoms.\n\nRequest: Formal visual field assessment, fundoscopy, and clinical opinion on aetiology of visual disturbance. Is this consistent with GCA-related visual loss, thromboembolic event, or alternative pathology? Patient has only one functioning eye - urgent assessment required."
    },
    {
      "item": "Request 12-lead ECG",
      "time_frame": "2026-02-22T14:00:00Z",
      "request": "12-lead ECG requested for Anthony Domaine (MRN 320761) on AMU. Patient with mechanical aortic valve, history of endocarditis, presenting with visual disturbance and transient neurological symptoms. ECG required as part of baseline workup to assess for arrhythmia (particularly atrial fibrillation) which could contribute to thromboembolic risk. Patient on warfarin but INR pending."
    },
    {
      "item": "Prescribe methylprednisolone IV",
      "time_frame": "2026-02-22T14:30:00Z",
      "request": "Prescribe IV methylprednisolone for Anthony Domaine (MRN 320761) on AMU. Patient with suspected giant cell arteritis presenting with acute visual symptoms in only functioning eye. Rheumatology previously recommended steroid initiation if further visual symptoms develop. Please check local guidelines for appropriate high-dose steroid regimen for GCA with visual involvement (typically methylprednisolone 500mg-1g IV OD for 3 days). Ensure INR is therapeutic before administration (mechanical aortic valve on warfarin). Patient requires urgent treatment to prevent irreversible vision loss."
    },
    {
      "item": "Consider imaging of aortic root",
      "time_frame": "2026-02-23T10:00:00Z",
      "request": "Consider dedicated imaging of aortic root for Anthony Domaine (MRN 320761). Patient has history of infected aortic root with replacement 2022, mechanical aortic valve, previous endocarditis. Recent PET-CT showed moderate increased uptake in aortic root region suggesting possible ongoing low-grade inflammation. CT head performed today extended to approximately thoracic inlet but did not fully capture aortic root. Given current presentation with possible embolic phenomena (visual disturbance, transient right arm weakness), recommend dedicated cardiac imaging (? CT aorta, ? TOE) to assess aortic root for possible infection recurrence or source of embolism. Please discuss with cardiology."
    },
    {
      "item": "Monitor visual symptoms",
      "time_frame": "2026-02-22T17:00:00Z",
      "request": "4-hourly visual symptom monitoring for Anthony Domaine (MRN 320761) on AMU. Patient has only one functioning eye (left) following previous right CRAO. Currently being treated for suspected GCA with visual involvement. Please document: any change in visual acuity, new visual field

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Refined clerking (43 days ago 13:32)

Refined clerking Sun 22 February 2026 13:32

Last Modified: 43 days ago

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Medical ST5 Miller Clerking
Thank you for referring this interesting case as a stroke call.

Presenting Complaint:
Visual disturbance

History of Presenting Complaint:
Patient presented with sudden onset visual disturbance at 09:00 this morning whilst eating breakfast. Developed blurring and haziness of vision in his left eye with inability to see objects at distance. Described vision as if his eye was not opening properly. At time of onset, associated with sweating, right arm aching in the antecubital fossa, and generalised weakness of the right arm. He took his own blood pressure which was 150mmHg (normally 120mmHg). Subsequently developed nausea with episodes of vomiting. Felt unable to stand from sitting position at home.

He has baseline blindness in his right eye from previous right central retinal artery occlusion. Today's symptoms affected his only functioning eye. On arrival to hospital, reported some improvement in left eye vision but not back to baseline. Described persistent blurring and haziness with difficulty seeing objects normally. Possible superior left quadrantanopia identified on initial examination.

Associated with right arm weakness which has improved from initial presentation when he was unable to lift the arm at all. Minimal right arm drift noted but with reasonable power. Also reported dull right elbow and right shoulder pain.

Patient has been under investigation recently for suspected giant cell arteritis following two previous episodes of blurring vision and flashing lights in his left eye. Recent investigations including temporal artery ultrasound, temporal artery biopsy, and PET CT scan have been inconclusive for giant cell arteritis. Rheumatology letter specifically recommends initiation of steroids if presents with further visual disturbances.

Recent PET also shows low grade inflammatory activity at aortic root - unclear significance of this.

Past Medical History:
• Previous right central retinal artery occlusion (2023) - resulting in no perception of light in right eye, right afferent pupillary defect
• Aortic root replacement (January 2022)
• Previous endocarditis - infected aortic root abscess treated 2022, repatriated from Derekud post-operatively, required reoperation for rebleed
• Previous aortic valve replacements - 2017 and 2022 (mechanical valve)
• TIA (December 2025)
• Non-diabetic hypoglycaemia
• Inguinal hernia/hydrocele
• Nerve damage to right leg secondary to groin access
• Glaucoma - under ophthalmology follow-up
• Small cataract left eye
• Hypothyroidism

Drug History:
• Atorvastatin 40mg PO OD
• Finasteride 5mg PO OD
• Pregabalin 50mg PO BD
• Furosemide 20mg PO OM
• Warfarin - 10mg 5 times per week, 9mg 2 times per week (as per INR)
• Bisoprolol 2.5mg PO OD
• Aspirin 75mg PO OD
• Lansoprazole 30mg PO OD
• Latanoprost eye drops
• Levothyroxine 125mcg PO OD

Allergy History:
NKDA

Social History:
Lives with wife. Independent at baseline. Enjoys gardening. Previous nerve damage to right leg affects mobility - has long-standing difficulty lifting right leg, uses assistance getting in and out of bed and car. Never smoker.

On Examination:
Alert, oriented. Initially some slowed responses with minimal effort in facial movements. Marked improvement noted 45 minutes post-admission.
NIHSS on admission: 6
NIHSS 45 minutes post-admission: 0
Cardiovascular: Metallic aortic valve heard with soft systolic murmur loudest in aortic area on expiration. No peripheral oedema.
Respiratory: Chest clear to auscultation.
Abdomen: Soft, non-tender.
Neurological:
• Cranial nerves: Left eye vision - blurring and haziness, unable to see objects at distance. Right eye - counting fingers (baseline). Visual fields - initially possible superior left quadrantanopia, improved on re-examination but persistent non-specific visual changes. Facial movements symmetrical. No dysarthria or slurring detected. No dysphasia.
• Upper limbs: Minimal right arm drift initially, resolved on re-examination. Right arm - 5/5 power all muscle groups, some subjective heaviness reported by patient. Left arm - 5/5 power. Finger-nose testing - initially past-pointing on right, resolved on re-examination. Normal on left throughout.
• Lower limbs: Left leg - 5/5 power. Right leg - baseline weakness with difficulty lifting off bed, longstanding secondary to peripheral nerve damage
• Sensation: Reduced sensation right leg (baseline). Otherwise intact to light touch throughout.
Skin: Single right thumb splinter haemorrhage. No other stigmata of endocarditis.
Investigations:
Venous Blood Gas (26/02/26):
• pH: 7.48
• Sodium: 129
• Lactate: 2.1

PET FDG Scan (20/02/26, reported 22/02/26):
• Moderate increased uptake in root of ascending aorta in region of aortic root collection - could be related to ongoing low-grade inflammation rather than large vessel vasculitis
• Moderate increased uptake in wall of root of ascending aorta in region of collection similar to background liver (intermediate grade 2 uptake)
• Uptake within wall of thoracic and abdominal aorta is low grade
• Asymmetrical increased uptake in region of fossa of Rosenmuller

Blood Tests (18/02/26):
• CRP: 2
• Normal LFTs
• Normal FBC

Right Temporal Artery Biopsy Histology:
• Marked intimal thickening
• Fragmentation of elastic fibres
• Few lymphocytes present in adventitia
• Numerous calcifications in wall thickness
• Findings may suggest temporal arteritis but inconclusive

Ultrasound Doppler Both Temporal Arteries:
• Right: Tortuous with mild intimal thickening 1.5mm, frontal vessel compressible with mild intimal thickening 0.4mm, normal waveform velocities, no halo or stenosis
• Left: Mild intimal thickening 0.7mm parietal and 0.4mm frontal, normal waveform and velocities

Carotid Duplex Scan (TIA Clinic):
• No evidence of significant stenosis in left internal carotid artery
• No evidence of cardioembolic source
• No LA thrombus identified

CT Head with Contrast (26/02/26):
• Nil acute and no large vessel occlusion

Impression:
Acute visual disturbance affecting left eye (patient's only functioning eye) with associated transient right-sided neurological symptoms, now largely resolved.

Differential Diagnoses:
1. Giant cell arteritis with visual disturbance - most likely given typical history, rheumatology recommendation for steroid initiation, and rapid improvement
2. Thromboembolic event affecting eye - possible given history of infected aortic root, mechanical valve, though compliant with warfarin and INR in range

Management Plan:
1. Blood tests including INR - to confirm therapeutic anticoagulation Target range 2-3
2. 12-lead ECG
3. Initiate steroids for presumed giant cell arteritis flare with gut and bone protection (Pred 60mg)
4. Urgent rheumatology review in morning
5. Admit to Acute Medical Unit (not stroke ward)
6. Warfarin 9mg today and tomorrow then back to 10mg

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Refined clerking (43 days ago 21:58)

Refined clerking Sun 22 February 2026 21:58

Last Modified: 43 days ago

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Medical ST5 Miller Clerking

Presenting Complaint:
Left visual disturbance

History of Presenting Complaint:
77-year-old gentleman presenting with acute onset left visual disturbance at 09:00 this morning. Was having breakfast and had taken usual medications when he developed blurriness and haziness in the left eye with an inability to see objects further away and a possible superior left quadrantanopia on initial examination. The right eye has no perception of light due to previous right central retinal artery occlusion. Associated symptoms included sweating, nausea, vomiting, feeling of presyncope, and inability to stand. Self-measured blood pressure was approximately 150 mmHg systolic, which is elevated compared to his usual 120 mmHg. He also developed dull aching pain in the right elbow and right shoulder with associated weakness and heaviness in the right arm, intermittently unable to lift it. His daughter-in-law attended and noted episodes of confusion with incorrect answers to questions and difficulty remembering how to do things at home.

He has been under investigation recently for possible giant cell arteritis (GCA) and is also under the TIA clinic for possible amaurosis fugax. Seen on 08/01/2026 in TIA clinic after referral with two episodes of blurring of vision and flashing lights in the left eye. The history was not entirely convincing of retinal artery occlusion. He was referred to rheumatology and underwent temporal artery ultrasound which demonstrated thickening but no other signs of inflammation, with normal CRP. There is a degree of uncertainty with the diagnosis from the stroke team. No evidence of significant stenosis in left internal carotid artery on carotid duplex scan. No evidence of a cardioembolic source such as LA thrombus identified. Temporal artery biopsy demonstrated marked intimal thickening, fragmentation of elastic fibres, and a few lymphocytes present in the adventitia with numerous calcifications — described as possibly suggestive of temporal arteritis but inconclusive. Whole body PET-FDG scan (22/02/2026) demonstrated moderate increased uptake in the root of the ascending aorta in the region of the aortic root collection, which could be related to ongoing low-grade inflammation rather than large vessel vasculitis; intermediate grade 2 uptake elsewhere; low-grade uptake within the wall of the thoracic and abdominal aorta; and asymmetrical increased uptake in the region of the fossa of Rosenmüller (referred to ENT). All investigations have been inconclusive for a definitive diagnosis of GCA although the history is typical. Rheumatology letter recommends initiation of steroids if he presents with further visual disturbances.

He also reports intermittent headaches described as throbbing, affecting the forehead or eye, likened to a migraine. These had been occurring every couple of hours but have improved recently. He additionally reports intermittent dizziness on looking up and down, which has been longstanding.

Has been compliant with warfarin throughout. Current warfarin dosing: 10mg five times a week and 9mg two times a week.

Past Medical History:
• Right central retinal artery occlusion — no perception of light in right eye (2023). Right afferent pupillary defect with evidence of previous embolic disease in the right retinal vasculature
• Infected aortic root abscess — repatriated from Harefield after surgery. AVR and aortic root bypass for infection (June 2022). Reoperated for re-bleed. Treated with meropenem and teicoplanin. Subsequent blood cultures negative
• Aortic valve replacement and root replacement (2017 and 2022) — mechanical aortic valve in situ
• Previous endocarditis
• Glaucoma
• Cataract (left eye)
• TIA (2025)
• Non-diabetic hypoglycaemia
• Iron deficiency anaemia
• Hydrocele
• Right femoral nerve damage (iatrogenic, from groin access) — longstanding right leg weakness

Drug History:
• Atorvastatin 40mg PO OD
• Finasteride 5mg PO OD
• Pregabalin 50mg PO BD
• Furosemide 20mg PO OM
• Warfarin PO as per INR (10mg x5 days/week, 9mg x2 days/week)
• Bisoprolol 2.5mg PO OD
• Aspirin 75mg PO OD
• Lansoprazole 30mg PO OD
• Latanoprost eye drops
• Levothyroxine 125mcg PO OD

Allergy History:
Not documented

Social History:
Lives with his wife. Independent. Goes out in the garden regularly. Multiple recent hospital appointments.

On Examination:
General: Alert, oriented, globally slowed with minimal effort on facial movements.

NIHSS on admission: 6
NIHSS 45 minutes following admission: 0

• Cardiovascular: Metallic aortic valve click heard. Soft systolic murmur loudest in the aortic region on expiration. No peripheral oedema. Single right thumb splinter haemorrhage noted. No other stigmata of endocarditis on hands or elsewhere.
• Respiratory: Chest clear to auscultation.
• Abdomen: Soft, non-tender.
• Neurological:
  - Cranial nerves: Right RAPD (known). Visual fields — possible superior left quadrantanopia on initial assessment, improved on repeat testing with clearer peripheral vision. No facial droop or asymmetry. Extraocular movements intact.
  - Motor: Initial right upper limb drift and heaviness with reduced ability to lift against gravity, but squeezing power preserved. Right lower limb — longstanding difficulty lifting off bed secondary to known right femoral nerve damage. Left upper and lower limbs — normal power.
  - Sensation: Symmetrical in upper limbs and face. Reduced sensation in right lower limb (longstanding, related to nerve damage).
  - Coordination: Finger-to-nose — initial past-pointing on right, improved on repeat testing. Left upper limb — normal.
  - Speech: Patient reports change in voice quality — slightly dry/husky character. No dysarthria or dysphasia detected.
  - Cognition: Oriented to time, age. Naming intact. Able to read.
  - On repeat examination: No residual limb weakness, no hemianopia, but persistent nonspecific visual changes and blurriness in left eye.

Investigations:
• VBG: pH 7.48, Na 129, Lactate 2.1
• CRP (18/02/2026): 2
• LFTs (18/02/2026): Normal
• FBC (18/02/2026): Normal
• CT head with contrast angiography (22/02/2026): No large vessel occlusion in the brain
• Whole body PET-FDG scan (22/02/2026): Moderate increased uptake in the root of the ascending aorta in the region of the aortic root collection — could be related to ongoing low-grade inflammation rather than large vessel vasculitis. Intermediate grade 2 uptake elsewhere. Low-grade uptake within the wall of the thoracic and abdominal aorta. Asymmetrical increased uptake in the region of the fossa of Rosenmüller (referred to ENT)
• Ultrasound Doppler of both temporal arteries: Right — tortuous with mild intimal thickening measuring 1.5mm, patent frontal vessel compressible with mild intimal thickening 0.4mm, normal waveform velocities, no halo or stenosis. Left — mild intimal thickening 0.7mm, parietal and frontal 0.4mm, normal waveform and velocities
• Right temporal artery biopsy (histology): Marked intimal thickening, fragmentation of elastic fibres, few lymphocytes in the adventitia, numerous calcifications. Possibly suggestive of temporal arteritis but inconclusive
• Carotid duplex (TIA clinic): No significant stenosis in left internal carotid artery
• 12-lead ECG: Requested
• INR: Requested

Impression:
Acute left visual disturbance with transient right-sided weakness (NIHSS 6 → 0) in the context of known mechanical aortic valve, previous aortic root infection, and ongoing investigation for possible giant cell arteritis.

Differential Diagnoses:
1. Giant cell arteritis flare causing visual disturbance
2. Thromboembolic event affecting the left eye
3. Cardioembolic event secondary to infected/inflamed aortic root

No symptoms of polymyalgia rheumatica.

Management Plan:
1. Bloods including INR, FBC, CRP, LFTs
2. 12-lead ECG
3. If INR within therapeutic range — initiate methylprednisolone IV (or high-dose steroid as per local GCA guidelines) to dampen inflammation potentially affecting left eye vision
4. If INR subtherapeutic — consider thromboembolic disease as primary aetiology; load with aspirin and discuss with ophthalmology
5. Ophthalmology review for assessment of left eye
6. Admit to Acute Medical Unit (not stroke ward)
7. Rheumatology review in the morning for decision on GCA diagnosis and ongoing management
8. Full escalation
9. ENT referral for asymmetrical uptake in fossa of Rosenmüller on PET-CT

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