Transcription - 20260226T 23-43.mp3

Lee roberts 675558 59 year old man stroke call to the emergency department at 5 minutes to 8 on arrival patient in ambulance seen in the back of the ambulance has been feeling generally unwell for the past few days with nausea vomiting and diarrhea has become has been febrile at home and generally weak and the team were planning to bring him to hospital however on their assessment found him to be weak but primarily on the left hand side as well as his background of previous brain malignancy they were concerned about stroke and so pre alerted for stroke on examination nih assess score of 8 14 and time of onset of symptoms circa 06:00 with the ambulance crew however symptoms slightly fluctuant in terms of left sided weakness he's globally weak and the symptoms are very fluctuant in that he's able to perform much better finger to nose performance with power than he is holding his arm up however we plan to scan his head brought around to the ct scanner no cannula cannulated blood's taken and scanned scanned initially interpreted by myself as large area of vasodermogenic edema possibly secondary to recurrence of brain metastasis however reported that there's a similar extent and distribution to the previous mri and was previously thought to be radiation induced changes within the deep white matter and there was no appreciable underlying mass lesion and very little interval change since the previous surgery the radiologist comments that he's very likely to have a degree of left sided deficit therefore impression most likely infectious gastroenteritis leading to dehydration and low flow state in the context of previous neurosurgery leading to stroke mimic with global but predominantly left sided weakness plan bloods iv fluids called away to several emergencies including periolescrew and major hemorrhage on return bloods have come back hemoglobin a 188 consistent with significant dehydration inr normal renal function creatinine a 121 from a baseline of 97 indicative of pre aki electrolytes normal alt 42 previously 40 glucose normal cholesterol slightly higher 6.2 however non fasting samples crp of 29 no previous for comparison urea 6.8 ast 28 and the ct head had been reported venous blood gas ph 7.34 with a lactate of 1.6 plan iv fluids to continue for resuscitation and to be clocked oh wow do we need to do that doesn't need to be clocked just iv fluids the the plan is so the impression is yeah we've said it already plan is iv fluids input output monitoring daily u and e bloods tomorrow no role for antimicrobials at this stage supportive care aim home once clinically improved tep not completed however can be undertaken on the post op wardrobe and there's no collateral available lovely lovely are you doing fine feeling okay got nothing going on yeah same as any improvement in that weakness at all still feeling crap alright you're alright your facial droop seems to be a bit better so that's good gonna have a listen to your chest is that alright yeah do you have any fluid or anything like that yet sorry need some big breaths for me again any pain in your tummy was you do that the okay while you've been here yeah I've been have you been sick while you've been here around 4 good and it's been how long 3 days I'm sorry mate look your blood test shows you've got signs of infection and raised markers of inflammation consistent with this gastroenteritis the ct scan of your head is reassuring doesn't show anything worrying there as the appearance is stable compared to your previous stuff I suspect this is because of your previous neurosurgery okay you've obviously got some brain lacking that side because it was taken out in the operation and so when you're ill for other reasons it can cause you to become weak on that side okay that's what's going on so we'll give you some fluids to make you feel better we'll get an x-ray of your chest to make sure you haven't got a chest infection and check your urine to make sure that's not infected either okay and then june they'll just prop you up does that sound okay yeah okay alright see you soon so you're done with the lee no it's not okay so 59 year old man medications list medothyroxine sodium 25 micrograms to be taken 5 times a week hydrocortisone 10 mg at breakfast and 5 mg at lunch and dinner epilim chrono 800 mg twice a day omeprazole 20 mg once a day keppra 1.5 g twice per day zonisamide z o n I s a m I d e 50 mg capsules total total daily dose 250 mg twice per day and problems list fatty liver epilepsy fibrillary astrocytoma excised 20 14 low grade glioma 20 30 well it's probably the same thing isn't it here's a fibular diastole hadoma diagnosed in 2013 and excised in 2014 esophageal reflux disease

Medical ST5 Miller Clerking
Date: 26/02/2027 23:55

Presenting Complaint:
Weakness, nausea, vomiting and diarrhoea

History of Presenting Complaint:
A 59-year-old male with a background of fibrillary astrocytoma (excised 2014) presented to the Emergency Department via ambulance at 19:55. He had been feeling generally unwell for the preceding three days with nausea, vomiting, and diarrhoea. He had been febrile at home and globally weak. The ambulance crew noted predominantly left-sided weakness in the context of his known history of brain malignancy and pre-alerted for a stroke.

On assessment, symptoms were fluctuant; he was able to perform finger-to-nose testing better than sustained arm elevation, suggesting a functional or metabolic overlay rather than an acute focal neurological deficit. Time of symptom onset was approximately 06:00 on the day of presentation as reported by the ambulance crew. No collateral history was available.

Past Medical History:
• Fibrillary astrocytoma - diagnosed 2013, excised 2014
• Low-grade glioma (likely the same lesion as above)
• Epilepsy
• Non-alcoholic fatty liver disease
• Oesophageal reflux disease
• Previous neurosurgery (2014)

Drug History:
• Levothyroxine sodium 25mcg PO 5 days per week
• Hydrocortisone 10mg PO with breakfast; 5mg PO with lunch; 5mg PO with dinner
• Sodium valproate (Epilim Chrono) 800mg PO BD
• Omeprazole 20mg PO OD
• Levetiracetam (Keppra) 1.5g PO BD
• Zonisamide 250mg PO BD (as 50mg capsules)

Allergy History:
Not documented.

Social History:
Not documented.

On Examination:
General Appearance: Unwell, globally weak, with fluctuating left-sided deficit. Facial droop noted on arrival, with some improvement observed during assessment.

• Neurological: NIHSS score 8/14. Predominantly left-sided weakness. Fluctuating power; finger-to-nose testing better preserved than sustained limb elevation. Facial droop, improving.
• Respiratory: Auscultation performed; findings not documented. Chest X-ray requested.
• Other: No IV access on arrival; cannula sited during assessment.

Investigations:
• Hb: 188 (elevated, consistent with significant dehydration)
• INR: Normal
• Creatinine: 121 (baseline 97, consistent with pre-AKI)
• Urea: 6.8
• ALT: 42 (previously 40)
• AST: 28
• Electrolytes: Normal
• Glucose: Normal
• Cholesterol: 6.2 (non-fasting sample)
• CRP: 29 (no previous result for comparison)
• Venous blood gas: pH 7.34, lactate 1.6
• CT Head (26/02/2027): Large area of vasogenic oedema. Radiologist reports similar extent and distribution to previous MRI, previously attributed to radiation-induced changes within the deep white matter. No appreciable underlying mass lesion. Very little interval change since previous surgery. No new acute intracranial pathology identified.

Impression:
Stroke mimic with global but predominantly left-sided weakness, most likely secondary to infective gastroenteritis causing dehydration and a low-flow state in the context of previous neurosurgery and pre-existing structural brain changes.

Differential Diagnoses:
• Acute ischaemic stroke (less likely given fluctuating symptoms and stable CT appearances)
• Recurrence of brain metastasis / low-grade glioma (less likely given no interval change on CT)

Secondary Issues:
• Pre-AKI (creatinine 121, baseline 97) secondary to dehydration
• Adrenal insufficiency on background steroid replacement therapy

Management Plan:
1. IV fluid resuscitation; strict input/output monitoring.
2. Daily U&E monitoring.
3. Chest X-ray to exclude pneumonia; urine dipstick/MC&S to exclude urinary tract infection.
4. No role for antimicrobials at this stage; supportive care.
5. Patient counselled: CT head appearances stable and reassuring; likely stroke mimic precipitated by gastroenteritis in the context of prior neurosurgery causing increased susceptibility to left-sided weakness when systemically unwell.
6. Aim for discharge once clinically improved.
7. Treatment escalation plan (TEP) to be completed; no collateral available at time of clerking.
8. Medical bed for ongoing monitoring and IV fluid management.

Summary

Investigations

Plans

Medical ST5 Miller Clerking
Date: 26/02/2027 | Time: 00:19

Presenting Complaint:
Weakness, nausea, vomiting and diarrhoea

History of Presenting Complaint:
A 59-year-old male with a background of fibrillary astrocytoma (excised 2014) was brought to the Emergency Department by ambulance, with a pre-alert for suspected stroke. Symptoms commenced approximately 06:00 on the day of attendance. He had been feeling generally unwell for the preceding three days with nausea, vomiting and diarrhoea, and had been febrile and globally weak at home. The ambulance crew noted predominantly left-sided weakness in addition to his global debility, and given his background of previous brain malignancy, activated a stroke pre-alert.

On assessment, an NIH Stroke Scale score of 8/14 was documented. Notably, symptoms were fluctuant: he demonstrated significantly better performance on finger-nose testing compared to sustained arm elevation, suggesting a non-fixed neurological deficit. No collateral history was available.

Past Medical History:
• Fibrillary astrocytoma - diagnosed 2013, excised 2014
• Epilepsy
• Fatty liver disease
• Gastro-oesophageal reflux disease

Drug History:
• Levothyroxine sodium 25mcg PO 5 days per week
• Hydrocortisone 10mg PO each morning; 5mg PO at lunchtime and evening
• Sodium valproate (Epilim Chrono) 800mg PO BD
• Omeprazole 20mg PO OD
• Levetiracetam (Keppra) 1.5g PO BD
• Zonisamide 250mg PO BD

Allergy History:
NKDA

Social History:
No collateral available at time of clerking.
Nil alcohol or smoking reported

On Examination:
General Appearance: Patient seen in the back of the ambulance on arrival. Globally weak. Facial droop noted, with rapid resolution with resuscitation
• Neurological: NIHSS 14. Globally weak with predominantly left-sided deficit. Fluctuant symptoms - markedly better performance on finger-nose testing than with sustained limb elevation.
• Cardiovascular: HS normal
• Respiratory: Clear bilaterally
• Abdomen: SNT no vomiting since admission

Investigations:
• Hb: 188 (elevated, consistent with significant dehydration)
• INR: Normal
• Creatinine: 121 (baseline 97, indicative of pre-AKI)
• Urea: 6.8
• ALT: 42 (previously 40)
• AST: 28
• Electrolytes: Normal
• Glucose: Normal
• Cholesterol: 6.2 (non-fasting)
• CRP: 29 (no previous result for comparison)
• Venous blood gas: pH 7.34, lactate 1.6
• CT Head (26/02/2027): Large area of vasogenic oedema initially noted. On formal radiological reporting, the extent and distribution were comparable to previous MRI appearances, previously attributed to radiation-induced changes within the deep white matter. No appreciable underlying mass lesion identified. Very little interval change since previous surgery. No new acute intracranial pathology.

Impression:
Stroke mimic with global but predominantly left-sided weakness, most likely in the context of infective gastroenteritis causing dehydration in a patient with background neurosurgical history
Pre-AKI

Management Plan:
1. IV fluid resuscitation - ongoing; input/output monitoring.
2. Daily U&E monitoring.
3. Chest X-ray and urinalysis to exclude infective precipitants.
4. No role for antimicrobials at this stage; supportive management.
5. Discharge once renal function stable and clinically better
6. AMU

Summary

Investigations

Plans

Medical ST5 Miller Clerking

Presenting Complaint:
Stroke mimic

History of Presenting Complaint:
A 59-year-old man presented to the emergency department after having felt generally unwell for the past few days, characterised by nausea, vomiting, and diarrhoea. The patient has been febrile at home and generally weak. The ambulance crew were alerted for a potential stroke, noting weakness primarily on the left-hand side upon assessment. The onset of symptoms was estimated at approximately 06:00. On examination, the patient exhibited significant left-sided weakness, though there was fluctuation in the severity of symptoms with better performance in fine motor tasks such as finger-to-nose compared to holding an arm up. A CT head scan was performed, which was initially interpreted as indicating large areas of vasogenic oedema likely due to recurrence of brain metastasis. However, subsequent reports suggested that there were no appreciable underlying lesions, and findings were consistent with previous MRI reports, indicating radiation-induced changes without interval change since prior surgery. The clinical impression is that the patient has infectious gastroenteritis leading to dehydration and a low flow state, mimicking stroke symptoms due to prior neurosurgery.

Past Medical History:
• Fatty liver
• Epilepsy
• Fibrillary astrocytoma excised in 2014
• Low-grade glioma excised in 2013
• Esophageal reflux disease

Drug History:
• Levothyroxine sodium 25 micrograms PO 5 times per week
• Hydrocortisone 10 mg PO BD
• Epilim Chrono 800 mg PO BD
• Omeprazole 20 mg PO OD
• Keppra 1.5 g PO BD
• Zonisamide 50 mg capsules PO BD (total daily dose 250 mg)

Allergy History:
• NKDA

Social History:
Patient lives independently. No significant mobility issues were noted. The patient does not require formal care and previously worked in an unspecified occupation. Ex-smoker, alcohol intake currently not specified. Functional status slightly impacted due to recent illness.

On Examination:
General Appearance: Alert, but unwell.
Observations: HR 88, BP 120/80, Temp 37.5°C, RR 18, O2 Sats 96%
• Abdomen: Soft, non-tender, no guarding or rebound tenderness
• Cardiovascular: Regular heart sounds, no murmurs, peripheral pulses normal
• Respiratory: Clear on auscultation, chest expansion normal
• Neurological: Left-sided weakness, fluctuating symptoms

Investigations:
• Bloods: Hb 188, INR normal, creatinine 121, ALT 42, glucose normal, cholesterol 6.2, CRP 29, urea 6.8, AST 28
• CT Head: No acute intracranial changes, stable compared to previous scans
• Venous Blood Gas: pH 7.34, lactate 1.6

Impression:
Infectious gastroenteritis leading to dehydration and low flow state, mimicking a stroke due to prior neurosurgery.
Differential Diagnoses: Stroke vs. stroke mimic due to prior brain surgery and infection.

Management Plan:
1. Continue IV fluids for resuscitation and input/output monitoring.
2. Daily urea and electrolytes bloods tomorrow.
3. No antimicrobials indicated at this time; supportive care initiated.
4. Discharge plans are contingent on clinical improvement.
5. Consider chest X-ray and urinalysis to rule out chest and urinary infections, respectively.
6. Further assessment by neurology if required depending on clinical progress.
7. Admit to General Medical Ward for observation and management.
8. Discussion regarding escalation and CPR status as necessary.

Summary

Investigations

Plans

Medical ST5 Miller Clerking

Presenting Complaint:
Acute left-sided weakness (stroke call) and diarrhoea/vomiting

History of Presenting Complaint:
59-year-old man with a 3-day history of nausea, vomiting and diarrhoea and fevers at home. Became generally weak and, on assessment by ambulance crew, was noted to have predominantly left-sided weakness. Time of symptom onset reported circa 06:00 on the day of attendance; weakness is fluctuating (patient able to perform some coordinated movements better at times, e.g. finger-to-nose, but has reduced power when maintaining arm position). NIHSS recorded at 8 on initial assessment. No preceding trauma. No clear new focal seizure activity reported. Collateral history obtained from ambulance crew. No other acute complaints.

Past Medical History:
• Fibrillary astrocytoma (diagnosed 2013, excised 2014) - low-grade glioma with prior neurosurgery
• Epilepsy
• Fatty liver
• Gastro-oesophageal reflux disease

Drug History:
• Levothyroxine sodium 25mcg PO five times weekly
• Hydrocortisone 10mg PO morning, 5mg PO at lunch, 5mg PO evening
• Epilim Chrono 800mg PO BD
• Omeprazole 20mg PO OD
• Levetiracetam (Keppra) 1.5g PO BD
• Zonisamide 250mg PO BD

Allergy History:
NKDA

Social History:
Not documented in the consultation.

On Examination:
General: Patient appeared unwell and weak; fluctuating left-sided weakness noted. Facial droop present but reported as improved compared with initial assessment. Patient had vomited earlier while in ED.
Observations: Venous blood gas pH 7.34, lactate 1.6. (No formal vital signs documented in transcript.)
Neurological: Predominantly left-sided weakness with fluctuating power; able to perform some coordination tasks intermittently; facial weakness noted.
Cardiovascular/Respiratory/Abdomen: No focal abnormalities documented on examination; chest auscultation planned; abdominal examination not specifically documented.

Investigations:
• Blood tests (on admission): Haemoglobin 188 (g/L), creatinine 121 (µmol/L) (baseline 97), urea 6.8, electrolytes within normal limits, INR normal, CRP 29, ALT 42, AST 28, glucose normal, non-fasting cholesterol 6.2.
• Venous blood gas: pH 7.34, lactate 1.6.
• CT head (urgent, on presentation): Large area of vasogenic oedema, no appreciable mass lesion or acute haemorrhage; appearance similar in extent/distribution to prior MRI and previously thought to represent radiation-induced changes within the deep white matter; little interval change since prior surgery. Reported as not showing acute ischaemic infarct to explain presentation.

Impression:
Infectious gastroenteritis causing dehydration and a low-flow state with resultant stroke mimic — global but predominantly left-sided weakness. CT head shows stable post-surgical/radiation changes with vasogenic oedema and no acute mass lesion. Secondary issue: history of brain tumour and prior neurosurgery contributing to baseline deficits on the left.

Differential Diagnoses:
1. Dehydration/low-flow state causing worsening of pre-existing unilateral weakness (stroke mimic)
2. Acute ischaemic stroke (less likely given imaging and fluctuating deficit)
3. Recurrent tumour or local mass effect (CT and comparison with prior imaging argue against new mass)
4. Infection (systemic gastroenteritis) with metabolic contribution to neurological deterioration

Management Plan:
1. Immediate: IV fluids commenced for resuscitation; continue IV fluids and monitor input/output closely.
2. Monitoring: Repeat U&E blood tests the following day; daily review of fluid status and renal function.
3. Infection control: No role for empirical antimicrobials at this stage; supportive care for presumed infectious gastroenteritis.
4. Further investigations: Chest X-ray to exclude chest infection; urine dip/culture to exclude urinary source of infection.
5. Neurology/stroke: CT head performed; no acute intervention indicated (no thrombolysis). Continue neurological observation; escalate if deterioration.
6. Disposition: Admit for ward-level care for fluids and observation (acute medical/medical ward). Aim for discharge home once clinically improved and renal function stabilised.
7. Patient communication: Explained CT head findings and that weakness is likely related to previous neurosurgery and current systemic illness; discussed plan for fluids, tests and monitoring with patient.
8. Escalation: No active plan for thrombolysis/ITU at present unless clinical deterioration.

Summary

Investigations

Plans

Medical ST5 Miller Clerking

Presenting Complaint:
Vomiting, diarrhoea and weakness

History of Presenting Complaint:
59-year-old man brought to the Emergency Department as a pre-alerted stroke call. He had felt generally unwell for the preceding 3 days with nausea, vomiting, diarrhoea, fever at home and generalised weakness. The ambulance crew had planned conveyance to hospital for this illness, but on assessment noted weakness, predominantly affecting the left side, in the context of previous brain malignancy and neurosurgery, and therefore raised concern for stroke.

Time of onset of worsening neurological symptoms was reported as approximately 06:00. Symptoms were described as fluctuant, with global weakness but predominantly left-sided weakness. On arrival he was assessed in the ambulance with NIHSS reported as 8. Examination of limb function was variable, with better performance on finger-nose testing than when holding the arm up.

CT head was performed urgently. Initial concern was for vasogenic oedema related to possible recurrence of brain metastasis; however, formal radiology report confirmed appearances were similar in extent and distribution to previous MRI, previously attributed to radiation-induced change within the deep white matter, with no appreciable underlying mass lesion and little interval change since prior surgery. This was felt likely to account for a degree of chronic left-sided deficit.

Overall clinical picture was considered most consistent with infectious gastroenteritis causing dehydration and a low-flow state, resulting in a stroke mimic on a background of previous neurosurgery. While in the department he continued to feel unwell and reported ongoing vomiting. He denied abdominal pain during review. He was informed that CT head appearances were stable and that his current weakness was likely exacerbated by intercurrent illness.

Past Medical History:
• Fibrillary astrocytoma diagnosed in 2013, excised in 2014
• Low-grade glioma
• Epilepsy
• Fatty liver
• Gastro-oesophageal reflux disease
• Previous neurosurgery for brain tumour excision in 2014

Drug History:
• Levothyroxine sodium 25 micrograms PO 5 times weekly
• Hydrocortisone 10mg PO mane and 5mg PO at lunch and dinner
• Epilim Chrono 800mg PO BD
• Omeprazole 20mg PO OD
• Keppra 1.5g PO BD
• Zonisamide 250mg PO BD

On Examination:
General appearance: Alert, feeling unwell.
• Abdomen: No abdominal pain reported on review.
• Respiratory: Chest auscultated; no specific abnormality documented.
• Neurological: NIHSS 8 on arrival. Global weakness with predominantly left-sided weakness. Symptoms fluctuant. Facial droop appeared improved on subsequent review.

Investigations:
• CT head: Stable appearances compared with previous imaging. Deep white matter changes consistent with previously reported radiation-induced change. No appreciable underlying mass lesion. Little interval change since previous surgery.
• Hb: 188
• INR: Normal
• Creatinine: 121, from baseline 97, consistent with pre-AKI
• Electrolytes: Normal
• ALT: 42
• Glucose: Normal
• Cholesterol: 6.2, non-fasting sample
• CRP: 29
• Urea: 6.8
• AST: 28
• Venous blood gas: pH 7.34, lactate 1.6

Impression:
Infectious gastroenteritis with dehydration causing a low-flow state and stroke mimic.
Differential Diagnoses: Urinary tract infection; chest infection.
Secondary issues: Previous neurosurgery with chronic left-sided deficit, pre-AKI, epilepsy, history of low-grade glioma/fibrillary astrocytoma.

Management Plan:
1. Continue IV fluids for resuscitation.
2. Monitor fluid balance with input/output monitoring.
3. Repeat U&Es tomorrow.
4. Provide supportive care.
5. No role for antimicrobials at this stage.
6. Request chest X-ray to exclude chest infection.
7. Check urine to exclude urinary infection.
8. Aim for discharge home once clinically improved.
9. TEP not yet completed; to be undertaken on the ward.
10. Best admitted under a medical ward/team.

Summary

Investigations

Plans