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Medical ST5 Miller Clerking
Date: 26/02/2027

Presenting Complaint:
Collapse and left-sided weakness

History of Presenting Complaint:
Monique is a 54-year-old female who works in radiology (covering CT, MRI, and ultrasound). She was attending work when she collapsed stepping off the bus, falling forward onto the ground. She is uncertain whether she lost consciousness but describes a period of amnesia around the event and found herself on the ground without recollection of how she got there. She sustained a scrape to her left arm and hand in the fall. She then felt dizzy walking into work and was assisted by a colleague.

On arrival she reported pins and needles and stiffness in her left arm, left-sided numbness, and left leg numbness. She also reported word-finding difficulties at the time of assessment. Visual disturbance was noted, with the patient describing blurred vision and diplopia (perceiving four images). She has had a background of left-sided weakness since a collapse two years ago (see below) for which she has been receiving physiotherapy with good progress until this presentation.

She reports a chronic daily migraine, managed with multiple medications. She took ibuprofen at approximately 12:00 on the day of presentation without benefit. She did not feel her headache was notably worse prior to the collapse.

In December, she fainted on two occasions following a steroid injection to her shoulder. On the Friday of the same week, she also had a further fall at work. She subsequently developed influenza that Saturday and attributed the December episodes to this illness.

She was previously reviewed by Dr France in June of the preceding year in the MTA clinic.

Two years prior, she collapsed whilst at work in CT. She was unable to speak, walk, or move her left side. This was attributed to a hemiplegic migraine.

Past Medical History:
• Functional neurological disorder (FND) - diagnosed prior to June of preceding year
• Chronic daily migraine (hemiplegic migraine - episode two years prior resulting in left-sided weakness)
• Severe asthma
• Left shoulder pathology - steroid injection December preceding year
• Ongoing left-sided weakness following collapse two years ago - under physiotherapy

Drug History:
• Sumatriptan - dose not specified
• Omeprazole - dose not specified PO OD
• Valproate - dose not specified
• Mirtazapine 30mg PO (frequency not specified)
• Montelukast 10mg PO (frequency not specified)
• Relvar Ellipta inhaler 92/22 micrograms inhaled OD
• Salbutamol inhaler - PRN
• Ibuprofen - taken 12:00 on day of presentation (PRN)

Note: "Birivamycin 2.5mg" as transcribed is unclear; drug name could not be confidently identified and has been omitted pending clarification.

Allergy History:
• Oranges - reaction type not specified
• Alcohol - reaction type not specified
• No known drug allergies documented

Social History:
Occupation: Radiographer, working across CT, MRI, and ultrasound.

On Examination:
General Appearance: Distressed, word-finding difficulties noted during consultation. In work uniform.

Neurological:
Cognitive screening (HSS):
- Age: Correctly stated as 54
- Month: Correctly identified as February
- Grip strength: Reduced in left hand
- Eye movements: Diplopia present; patient reports quadropia
- Visual fields (confrontation testing): Left homonymous field defect suggested - impaired peripheral vision in left field bilaterally on confrontation testing; able to detect finger on direct gaze but not in peripheral vision
- Facial movements: Smile, eye closure, eyebrow elevation, tongue protrusion - all intact
- Upper limbs: Left arm - able to generate some power but limited by pain in left shoulder; right arm - full power, held up for 10 seconds without drift
- Lower limbs: Bilateral leg power +1/5 on testing (both sides)
- Coordination: Finger-nose testing right hand - intact; left hand - unable to localise finger, no past-pointing identified; patient attributed difficulty to visual disturbance
- Sensation: Sensation to touch - symmetrical over head and knees; subjective numbness left arm and left leg
- Speech: Word-finding difficulties noted intermittently during consultation; no dysarthria

Investigations:
• Bloods (reported 25/02/2027 - reviewed by GP): Results not available
• X-ray left wrist/hand: Requested - awaiting

Impression:
Hemiplegic migraine with associated neurological symptoms (left-sided weakness, diplopia, word-finding difficulties, left-sided numbness) in the context of a background of chronic migraine and FND.

Differential Diagnoses: Transient ischaemic attack / stroke has been considered but the clinical pattern was assessed as not consistent with typical stroke presentation by the assessing clinician and stroke nurse (Neo). FND exacerbation remains a differential.

Management Plan:
1. Monitoring: Observe response to migraine treatment; monitor neurological status.
2. Investigations: X-ray left wrist/hand to exclude fracture following fall. ECG to be requested (deferred at time of assessment - to be arranged via nursing staff). Bloods reviewed by GP yesterday - no acute results noted. CT head deferred pending response to treatment; to be reconsidered if no clinical improvement.
3. Treatment:
   - Aspirin (dose not specified) PO - single dose
   - Sumatriptan PO - dose per standard dosing
   - Metoclopramide PO - dose per standard dosing, for migraine-associated nausea
4. Review response to analgesia and anti-migraine treatment. If no improvement, reconsider neuroimaging.
5. Patient reassured that presentation is not felt to be consistent with acute stroke at this time.
6. Neurology (Neo - stroke nurse) aware and involved in assessment.
7. Current location: Emergency department. Ward admission not planned at this stage pending treatment response.
8. Escalation plan: Not formally documented at this time.

Summary:

Investigations:

Patient Details

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