Trevy t r e v y crabtree 1 389337 30 year old man medications list multiple acute prescriptions of mirtazapine amitriptyline sumatriptan nefepam omeprazole codeine no current repeat medications from a un gp record you can see that requested his that he's been going through with low mood from the march 23 word for the last few months more in the last 4 to 5 weeks poor energy wife has some sort of medical problem a tumor 2 children at home age 4 and 2 not working migraines currently 3 times per week since amitriptan has been twice a week amitriptan does appear to be helping sleep started 2 weeks ago concerned of interaction with sumatriptan and ssris discussed I would not want to prescribe sri with sumatriptan there may be less risk for mirtazapine but unclear to me aware that fatigue worsens the migraines also add mirtazapine not to take triptan but also increase amitriptan if drowsy on mirtazapine aim to increase dose looking to move to ground floor flat and having carers after his wife's surgery then further discussion with 7 days later with his gp saying that the he wants to come off his tablets because he's having pains down his face restless legs blurry vision and intense tiredness on mirtazapine feeling sedated in the mornings his symptoms are worse on a combination of mirtazapine and eletriptan the gp said to stop the betazepine and agree with you again in 2 weeks then a day late or 2 days later he said he had jaw aura on and off for hours without migraine jaw goes weak and tingly it goes droopy been happening about a year yesterday didn't get a headache and then saw his gp recently worsening migraine with aura starts on amitriptyline it helping a bit then yesterday stressful at home stood up felt dizzy woozy felt numbness to the left side of his face and drooping today ongoing numbness and also some weakness numbness to the left arm on examination they found subtle left sided facial drooping with a normal eyebrow raise and normal sensation normal tongue movements power on the left arm 4 out of 5 he's had some investigations with us usernies normal lft is normal apart from alt of 50 which has been up and down over the years crp of 3 ast normal urea normal full blood count mcv 81.6 but remainder of l full blood count normal b 12 and folate normal note multiple presentations under the surgical team with abdominal pain which right upper quadrant pain worse after eating and recently underwent nuclear medicine hepatic biliary function scan which showed abnormal gallbladder filling with preferential biliary drainage directly into the small bowel plan for mrcp after review of benign hepatobiliary mdt past medical history depression migraine seen in vestibular clinic for a labyrinthine disorder past medical history family history of stroke and diabetes post traumatic stress disorder coded april 2022 depression coded 20 21 chronic alcoholism with major alcohol dependence in 2020 fibromyalgia coded 20 20 tietze's disease coded 20 20 metabolic associated fatty liver disease 2019 somatoform pain disorder diagnosed 2019 with depressed mood and anxiety coded before that so can you give me a hand to make it easier for you to drive or are good no you're an expert driver around here we're just in here hello ian how are you not so good I have quite a lot of blood though are you so you're better of course yeah what would you like to do would like to stay in the chair or would you like to get into bed for a bit so we can have a chat shall I shall I reverse you in and then we can have a chat does that sound good okay I'm an expert I've got that option give it a go oh it's cleaning off oh it's like grabbing the eye of a needle oh no look at that who have you got with me with you this mom yeah hi I'm rob I'm 1 of the medical residents nice to meet you nice to meet how are you good good what's been happening that's good alright tell me all about that okay okay I've been here yeah for about a couple of years mhmm for the last year I've been experiencing a year mhmm that electrically numb numbing sometimes mhmm and it only happened once few months and then I went to the doctors about 3 weeks ago because it was getting getting worse and so it could be a before amigiline mhmm put me on amitriptyline right and since then I've been on etazepine mhmm then do you mean alongside the amitriptyline yeah mhmm sunday sunday night I was getting zaps down my face on the right hand side yeah mhmm a restless leg just this 1 mhmm so the doctor on monday took me off because of him I was getting blurred vision as well oh so they took me off that on monday and then yesterday I got the the aura mhmm they lasted about 5 hours no migraine and there was dizziness lots of all weird peculiar things but chest pains I thought it was just stress kind of thing were you stressed there's a lot going on in my mind so I read a little bit about it now about your your wife yeah because that 1 yeah yeah my wife thought I should come in mhmm she's poisoned my okay because I've I've had some droopiness at times have you mhmm and have you got any droopiness now I don't know I don't think you have what do you think ma'am I think it's a little bit soft that's good but it's been it's not been electric if it feels like I've been in the dentist building up there's none yeah then I'll get a little bit electricky mhmm well yeah okay it's it's cold anyway I I slept it off this morning mhmm complete heaviness on the left hand side yeah and and the heaviness they're not normally it would go away which has been there all day heaviness and droopiness now and then apparently and yeah the electric heat type things there and did the symptoms come on suddenly or did they come on gradually just since I've got a couple of spin there fine so you woke up with the symptoms but then they've been fluctuant over this time is that fair to say there's always been a there's always been a heaviness always been a heaviness in my arm and there mhmm but the pins and needles come and go mhmm I'll get random I haven't had my migraine still haven't had the migraine but I've had headaches random headaches but they're not been like your normal migraines my normal migraine but before I got a zap there and then in my arm it's just random it feels like nervy kind of stuff and before we did all of this mucking around with your amitriptyline and your mirtazapine you would have had sumatriptan for these attacks would you yes if you felt these auras you would have sumatriptan as that first say and did you find it effective yes fine fair enough and then we've stopped it now because we've tried to put you on mirtazapine back on I'm now back on it now they're looking up on the family fine good did you use your sumatriptan no fine fair enough because you felt like it was too soon too soon after stopping the mirtazapine yeah fine fair it probably takes bit of had no no migraine migraine yeah but do you associate these symptoms with an aura at all like a kind of feeling or not not really the tingly and the electric shocks and things like that is that what you normally get before migraine or no this feels more intense more intense yeah so you do get similar symptoms but it's more intense now yeah yeah not in my arm yeah of course is new mhmm and not the dentity type feel mhmm it's more just it's more just a bit pins and needles mhmm a bit bit numb but nothing like that mhmm and it only last a few minutes mhmm but but this is abnormal or you it's been lasting since the morning yeah and then thinking back to yesterday yeah you said a sunday night it's wednesday now yeah what so what changed on sunday night and over the last 3 days sunday night is when I get it's a bit of zaps in my face and on the other side and the restless leg on the right and has that persisted or has that stopped now I get zapped but not the rest of mhmm restless leg zap on the right yes mhmm alright and how about your speech do you feel like your speech is affected at all I'm struggling to get my words out sometimes mhmm mhmm but you're not slurring your words which is good it it it just it literally just feels like I went to the dentist mhmm and it's just a bit you know dentist I'll just mhmm of course get the first bit out and then it's alright mhmm mhmm yeah fine okay and how have you been feeling over the last few months obviously your mental health has taken a hit with everything that's been going on at home sounds like and how have you been feeling physically yourself have you had any fevers or weight loss night sweats anything like that not a nice question good my eme's got worse I've been bed bound a lot more that's why I'm moving to my that's why I'm moving my been because I can't get up and lord I'm so sorry doing you just feel exhausted all day yeah I'm sorry that's shit isn't it I read about that yeah I mean oh last morning I think they're planning to do an mri scan of your of your bile ducts sunday great that'd be good right to see what's going on there see if we can find a fix for you make sure there's not stone blocking or something like that being in pain a lot of the time is obviously the foot and joint fatigued as well yeah I'm sorry yeah now and then yeah well this I've got a picture but it just looks a bit dead sometimes on the left yeah yeah show me your picture what are you worried about what do you think this could be I think it's a nerve maybe mhmm or I don't know everyone keeps saying mini strokes or me but mhmm I don't know it'd be very strange for symptoms to fluctuate as they are for you with a mini stroke with a mini stroke yeah it is funny it that's the right 1 and your left 1 is a little bit more red when was that this morning this morning and is that your stick in the background of small stick okay is is that how you get around the house normally full crawl oh crawl you're really in inside yeah gotcha sorry and how often do you get out of house last week full time or you've had to get around wheelchair really kind like this mhmm well I've I've got no strength to push myself today normally I'd be able to and you normally drive yourself fine okay yeah do a big step down for you it's like I can feel it I can do things but I don't feel full strength understood well okay I'm bit concerned as well because it's it's under she's a a couple of minutes I mean obviously she's a lot lots you see lots of I feel better than I did yesterday good it it I didn't feel like I was like just felt spaced out I just felt really peculiar mhmm I was rested and woke up and it just stayed like that of course and like I say would be very uncommon for a mini stroke to fluctuate like this usually they would have symptoms that last for an amount of time and then they would resolve and they wouldn't go back again in such a short. Of time so that goes against mini stroke and a proper stroke people have persistent neurological symptoms that don't get better without significant a lot of rehabilitation in time I've been asked to exclude a stroke by your gp which is fine and I think standing ahead is a very sensible thing to do to exclude that given your symptoms have been going on for since at least sunday we should see some changes on a ct scan to see if there's any sign of a stroke if you've had a stroke overnight I'll be honest with you it's too early to see on a ct scan however your symptoms from sunday if they were a stroke they would show up if that makes sense and in terms of symptoms today do you mind if I examine you is that alright just get a tendon around and get the reflexes but if it was a stroke yes it won't show up unfortunately I won't it's too early to see it yeah so strokes on ct scan show up days after as opposed to immediately you don't have a good test for it I'm the test for it does that make sense now your blood tests are in plum normal by the way which is obviously good there's nothing clearly upsetting you or making things worse or anything like that okay then we just get a 10 amr if you want okay thank you so so you're the 10 amr I don't know what you have to do oh and I didn't even have to meet I didn't even have to meet because I was to treat you I still got to see you so I'll start by testing the femoral and you're you're on to test what I'm doing yeah where are you ram and you just run up the scale okay let me do all you need to just to assess your legs for that matter okay and this is that's the next 1 okay that's fine 4 now can you put your arms up like this me check it could you do this with you no just be really strong and don't let me do that that's okay push down against me very good and push her get up against me very good goes like this like a boxer you're be strong don't you very good coming towards me very good upside it k and is that like this small turns out like this 1 with your fingers spared apart as well as you can get them don't let me push them together don't let me push them together that's good now thumb to little finger if you can that's lovely don't let me pull it apart that's important thank you very gently reflexes okay that's all we're doing so I'm firing around these things just relax if you can I know it's hard to give some in your arm but I won't drop any prunes okay fine you can come back I'm gonna just come to this side for a second I won't drop it no problem come back out just to test the sensation in your arms can you feel me touching you here yeah yeah can you hear on your thumbs yeah and to your own little fingers yeah feel the same on both sides yeah think it's not and all the same yeah good that's fine can I check the coordination of your head essentially I'm gonna ask you to put 1 hand down like this clap on it and lift your hand up turn it over and do a backwards clap then up over forward flap up over backwards flap there we go very good keep going if you can lovely any faster very good very good and then the other side 1 second now could you take your index finger and touch your nose okay and touch my finger and touch your nose to my finger k great and I'll try with the other side if you don't mind k yeah no worries good you're a bit slow but you're very active on that side which is good no problem do you mind if I check your legs is that okay just move them back and forth okay so gonna I'm get my hands up okay gonna sort of see these squeezes a little bit difficult can you transfer my thumb up on the bed yeah thank you give me a hand if you need please that's good just just to shrink the knee just to finish any weakness in your legs as well as in normal yeah quite a little bit just touching now that's been mostly yeah that's normal know the impingement there with the hip I see yeah you know I've heard about that as well so yeah that that's normal mhmm that gives way sometimes okay alright well can you lift this right leg up to me which and don't really push it down very good and then how about the second yep just hold this locked it down yep and you're then getting this is gonna get your heels a bit more towards your bum okay so you're feeling well I guess you're feeling well okay yep no good good good you're me out as well you're strong usually do the same thing I feel I feel strong you don't make me feel very strong feel me touching you yeah and here just a little and here and how about here on the back of the heels I feel it just a little more stained feathery yeah I can feel it and it feels slightly off yeah yeah it's that long standing or is it I don't know yeah no it's tickled me why not a bit more it's not my job by nipple that's true just check the reflexes you just relax if you can got some pain on your trousers you've been painting was it wish bloom or something I was a painter few months ago yeah right yep what were you painting the walls okay 2 year old what did they draw yeah living feel me touching you on your feet yeah feels more feathery on that left hand side yeah and a big unpleasant feeling on the bottom of foot sorry just gonna touch on that so I'll have that handy quick then the next thing is just a coordination in your legs so I need your shoes off because sometimes they're a bit heavy but I'll ask you to take your heel take it up to your knee and then slide it down your shin as accurately as you can and then kick it up into the air does that make sense I'll show you if you like so I'd like you to lift your knee up and pull into your knee and roll over knee just like that I'm to your up give me 20 pounds that's helpful lovely and down then back to your knee again okay and then try and do the side and then now just slide it over the throat of your shin very good I can keep my hand that's great that's fine that's fine so that's all sorted there thank you for letting me do that fine I can't do that any clear weakness on this side of your body that's good so you think you have momentary weaknesses in that side certainly but you were when you're underneath that you're still quite strong which is good in terms of your head and face I'll just wash my hands and touch your feet I don't know I touch your face I'm so sure it's well I think my hands are fine I'm just going to it's not like if someone just touched my feet and then touched my face I can't even get very much so any change to your sense of smell no no that's fine how about your vision any change to that just a little bit blurry last week a little bit blurry last week yeah now not now I I zone in and out a little bit no I think I'm tired sure of course you're we're gonna let me wait to your environment I test the fields in your vision is that okay if you put your right hand over your right eye can't help me can you see my finger here yeah maybe the fat doesn't so and pinch you slightly can you see my finger here yeah okay yeah here now how about here yeah yeah and here yeah very good just relax there if that's okay here yeah and here yeah here yeah and here yeah now if there's no parts of your vision missing you can see all of my face yeah good that's fine just shine a light in here I've got dishes tomorrow oh great that's half the test john no I'm not that good unfortunately alright and then could you look at that corner of the room for me just look up to the ceiling and then I'll ask you to look at your look at your ceiling very good back up to the corner of the room and for my finger again yep that's good very good just follow that please just to test your own movements a bit forward with the hat can you go back yeah that's fine alright and then do a competition there not now before had a bit of pain in the ring room which on the right eye the pain behind your eye yeah or moving your eye just at rest just just at rest okay feeling more touching on the face here yeah here yeah and here do feel the same in both sides there felt like before february right it felt that and that sinus all around and the right hand side got quiet yeah that's great can I test you at facial movements yeah you're able to get in there okay do you need a big smile yep great nice big smile that's great can you clap any cheeks for me no I can't I can't okay can you look right over there no very good just close with your arms and your shoulders you don't really need any that's great no any cheeks no good can listen to your tongue okay can you take it out really fine though ah can't see that line there say again for me ah very good 1 more time ah I just need to push it down with something just get little woody stick yeah I'm just gonna ask you to switch things I can't see you so I'll go what your hands are like don't depress them oh they're not in there oh that'll be why then I'm just gonna move on top and lower thank you very much yes alright you're welcome I'm looking at the back that felt more maybe it was little bit yeah a little bit less on the right you change it or a little less a little less on the right now and it before was a little less on the left that was louder like second time and the and the first time less on the first time 1 more on the second time so not clearly localizing to 1 side not this mhmm well great that's fine that's all that then so you do have as you say there's an ms of slight of facial movement on that it's very atypical to get facial signs only with stroke if you had the nerves that supply the face facial movements come from the brain they're very very common to have a stroke small enough that would cause just facial weakness and no other body weakness given your symptoms of migraine I think I think this is all migraine given the ongoing pain you have people with strokes don't tell me they've had pain don't tell me they've got tingling when I go to assess them they just can't feel me they don't tell me it's those 2 things together not because electrocuted to me it feels like nerves people with strokes don't tell me that they don't tell me they have any symptoms at all until I go to assess it and they say that I can't feel it at all so I think those things together make me think it's much less likely to be stroke I still think it's worth getting ahead and making sure there's nothing worrying there going make sure that gets sorted mhmm and then if that's normal I think we can get you out of it can get out it can to the office does that sound alright in the meantime shall I get you some aspirin I think aspirin works really well for migraine related headaches also the treatment for aspirin thank you for taking the time no it's a pleasure it's really nice to meet you let me get the nurses to get you those few things and I'll get the ct scan so that that gets us sorted I'm booked to have an mri scan really on your head yeah I haven't got a booking yet great fine so is that alright to have the mri that's fine yeah mri is a better scan which if you if we had an mri scan now we'd be able to look at an acute stroke mhmm but but it's a helpful thing to do definitely yeah tell us still have the mri still have the mri yeah ct gives us different it rules out big worrying things think now okay but and it rules out an old stroke as it caused some symptoms okay but okay yeah cool any questions or anything like that no no it's fine it's not a pleasure I'm just gonna wait so long I'll in the next 1 no no fine fine I will can I ask you to get back in your chair and go back out there to the room and then they'll grab you for the ct scan from there okay is that alright and we'll once the ct scan comes back we can we'll be questioning okay so if everything gets better we'll have to stop okay test I'll check that's what I'm saying yeah but I don't I don't that's so on examination cranial nerves normal subjective left sided tingling however and maybe possibly reduced sensation over the jaw upper limbs and lower limbs objectively normal power throughout but with some fluctuation in the power on the left hand side however when surprised has good power throughout on the left hand side possible left facial droop however seen moving face normally throughout consultation until the time of cranial nerve assessment when slight left facial droop noted however throughout consultation laughing etcetera there was no evidence of left sided facial droop impression most likely left sided weakness as part of aura with migraine secondary to cessation of sumatriptan which patient was using for migraines and starting of mirtazapine full stop plan restart sumatriptan and encourage to take 900 mg of aspirin ct head 900 mg aspirin if no bleeding on ct head should be metoclopramide if ct head normal discharge handed over to medical sho many thanks zarah