Transcription - 20251106T 15-17.mp3

Timothy albert 707613 42 year old man presenting complaint right facial droop paragraph history presenting complaint woke this morning at 07:00 in the morning and found that he could not move the right hand side of his face full stop paragraph wife says that has been feeling particularly stressed lately over the last 10 days however no evidence of intercurrent illness and no symptoms of upper respiratory tract infection ear or nasal infection full stop paragraph went to his e went to his gp who sent him to a and e because of this full stop no limb weakness full stop paragraph past medical history long standing hypertension investigated by the gp with euze and knees which were normal and a ultrasound of his abdomen which didn't demonstrate any renal artery stenosis but no other young hypertensive investigations undertaken full stop has been prescribed ramipril however he says did not improve his blood pressure and so he's not been taking it full stop blood pressure 220 systolic in the triage room full stop paragraph past medical history usually fit and well paragraph social history lived his wife paragraph no known drug allergies paragraph observations respiratory rate 18 sats 97% on air pulse 83 temperature 36.2 blood pressure 215 over a 153 investigations hi it's tessa wang ultrasound kidney october 2025 mildly large kidneys otherwise no abnormality detected ct head normal impression oh on examination cranial nerves examined right sided facial weakness in the pattern of the facial nerve but without forehead involvement right eye weakness and droop with right facial droop forehead not involved partial bell's palsy no limb weakness mobilizing independently stop as long as he's you know will report some dizziness intermittently over the day full stop paragraph impression most likely partial bell's palsy however significant risk factors for stroke given uncontrolled hypertension plan number 1 ct head number 2 if ct head negative for bleed for aspirin number 3 discussed with stroke consultant discussed with stroke consultant doctor helen harris advised to agrees that may agrees with impression to give 300 mg of aspirin send renin angiotensin aldosterone levels send metanephrines in a 24 hour urine collection for metanephrines and consider referral to the young hypertension service with endocrinology and to treat a stroke for now full stop and to and then manage hypertension with enteral treatment options first however may require parenteral management full stop

Medical ST5 Miller Clerking

Presenting Complaint:
Right facial droop

History of Presenting Complaint:
Woke this morning at 07:00 and found that he could not move the right side of his face. Wife reports he has been feeling particularly stressed over the last 10 days. No evidence of intercurrent illness and no symptoms of upper respiratory tract infection, ear or nasal infection. Attended GP who referred him to A&E because of the facial weakness. No limb weakness reported. Reports some dizziness intermittently throughout the day.

Past Medical History:
• Long-standing hypertension - investigated by GP with U&Es (normal) and abdominal ultrasound (no renal artery stenosis demonstrated)
• No other young hypertensive investigations undertaken
• Usually fit and well

Drug History:
• Ramipril (prescribed but discontinued) - patient reports it did not improve blood pressure so stopped taking it

Allergy History:
• NKDA

Social History:
Lives with wife

On Examination:
General Appearance: Alert, mobilising independently
Observations: HR 83, BP 215/153, Temp 36.2°C, RR 18, O2 sats 97% on air
• Neurological: Right-sided facial weakness in the pattern of the facial nerve but without forehead involvement. Right eye weakness and droop with right facial droop. No limb weakness.

Investigations:
• Ultrasound kidneys (October 2025): Mildly large kidneys, otherwise no abnormality detected
• CT head: Normal

Impression:
Most likely partial Bell's palsy
Differential Diagnoses: Stroke (significant risk factors given uncontrolled hypertension)

Management Plan:
1. CT head completed - normal
2. Aspirin 300mg
3. Send renin-aldosterone levels and plasma metanmephrines
4. Send 24-hour urine collection for metanephrines
5. Consider referral to young hypertension service with endocrinology
6. Treat as stroke for now pending further investigation
7. Discussed with stroke consultant Dr Helen Harris who agrees with impression and management plan
8. Manage hypertension with GTN patch and restart ramipril

Summary

Investigations

Plans