Physician's Assistant

Patient Details

Refined clerking (28 weeks ago 00:18)

Refined clerking Mon 22 September 2025 00:18

Last Modified: 28 weeks ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Headache and neurological symptoms

History of Presenting Complaint:
Three days of severe splitting frontal headache. Today at 3pm developed dizziness, continuing headache and "slurred speech" whilst at residential care home. Speech symptoms had resolved by the time ambulance crew arrived. However, ambulance crew identified left sided leaning with left sided visual disturbance and left visual field defect.

Well recently otherwise with no other complaints.

Past Medical History:
• Osteoporosis
• Congestive heart failure
• CKD Stage 4
• Atrial fibrillation
• Acute NSTEMI (2021)
• Pacemaker in situ (2016) for complete heart block
• Osteoarthritis
• Hypertension

Drug History:
• Mirtazapine 50mg PO ON
• Furosemide 40mg PO OM
• Laxido 1 sachet PO OD

Allergy History:
NKDA

Social History:
Lives in residential care home. Independent in toileting and eating. Has been recently rehabilitating walking up to 50 metres with zimmer frame.

On Examination:
Alert GCS 15
• Cardiovascular: Normal heart sounds, chronic venous changes in legs without evidence of infection or cellulitis
• Respiratory: Normal respiratory sounds
• Abdomen: Soft, non-tender
• Neurological: No dysarthria or aphasia present. Good power in all four limbs. Flattening of left nasolabial fold but no significant facial droop, forehead spared. Patient leans to the left but no clear inattention. Visual fields difficult to assess due to patient unable to open eyes widely, but no clear lateralising visual field deficit identified. 
• Other: Dressed wound to right arm

Investigations:
• Potassium (July): 4.9
• Sodium (July): 138
• ALP: 238 (previously 175)
• CRP: 13
• Urea: 17.8
• FBC: 122
• Blood gas: No acidosis
• CT Head: No acute intracranial haemorrhage or ischaemia, age-related cerebral atrophy and bilateral oligodendrogliosis, no skull fracture
• ECG: Atrial flutter with demand pacing, rate 85

Impression:
Possible small lacunar infarct with rapidly resolving symptoms

Management Plan:
1. Overnight observation and monitoring
2. Consider discharge to residential home in morning if stable
3. Patient not candidate for revascularisation therapy given age and functional baseline
4. Aspirin
5. TEP previously discussed. WBC

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Refined clerking (197 days ago 23:59)

Refined clerking Sun 21 September 2025 23:59

Last Modified: 28 weeks ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Headache and facial droop

History of Presenting Complaint:
Elderly patient with headache as primary presenting symptom. Unclear neurological presentation with atypical features. Patient currently residing in nursing home with functional baseline. No clear history of acute onset or specific neurological deficit described.

Past Medical History:
• Osteoporosis
• Congestive heart failure
• CKD stage 4
• Atrial fibrillation (not anticoagulated)
• Acute NSTEMI (2021)
• Pacemaker in situ (2016) for complete heart block
• Osteoarthritis
• Hypertension

Drug History:
• Mirtazapine 50mg PO nocte
• Furosemide 40mg PO mane
• Laxido 1 sachet PO OD

Allergy History:
Unknown

Social History:
Resides in nursing home
Functional baseline prior to admission
Age 100 years

On Examination:
General Appearance: Unable to open eyes widely
Observations: Unknown
• Cardiovascular: Normal heart sounds
• Respiratory: Normal respiratory sounds
• Abdomen: Soft, non-tender
• Neurological: Good power in all 4 limbs. Vision difficult to assess due to patient unable to open eyes widely. Struggled with left lateral hemianopia, however full vision in right eye. No clear facial droop on smiling, however slightly flattened left nasolabial fold which spares the forehead
• Other: Chronic venous changes in legs without evidence of infection or cellulitis. Dressed wound to right arm

Investigations:
• Potassium (July): 4.9
• Sodium (July): 138
• ALP (July): 238 (previously 175)
• CRP: 13
• Urea: 17.8
• FBC: 112
• Blood gas: No acidosis
• CT Head: No acute intracranial haemorrhage or ischaemia. Age-related cerebral atrophy and bilateral changes. No skull fracture

Impression:
Possible stroke, however atypical presentation with headache as primary presenting symptom and unclear neurology
Secondary issues: Multiple comorbidities including heart failure, CKD stage 4, atrial fibrillation not anticoagulated

Management Plan:
1. Ongoing monitoring in hospital setting
2. Consider antiplatelet therapy, however medications have been rationalised at nursing home
3. At age 100 with functional baseline, not candidate for revascularisation therapy
4. Discharge back to residential home in morning would be most sensible approach
5. Patient at risk of stroke due to atrial fibrillation not anticoagulated
6. Symptoms currently not disabling
7. General medical ward bed
8. Escalation plan: Given age and comorbidities, palliative approach likely appropriate

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Summary:

Investigations: