The expressive dysphasia is a clear indication there is focal neurology. Be extremely cautious about diagnosing a migraine in this situation, although there are Neurologists that describe the so called “hemiplegic migraine”.

But.. There is no headache.

And there is…. A systolic murmur

So….
Systolic murmur
Focal sudden onset neurological symptoms that resolve within 24 hours?

This is a TIA as a result of a paradoxical embolus from the right side of the heart (venous system) to the left side, and subsequently to the brain.

So what should be done?

Echocardiography and a cardiac catheterisation +/- insertion of an umbrella device to close the gap.

J

Common things are common, after all.

This high-flying investment banker took a career break of 6 months to work overseas in developing countries. There she was regularly eating uncooked meats, leading to her infection with T.Solium and T.Saginatum. (Not to mention her hookworm – that anaemia isn’t just due to menorrhagia, you know).

The resultant neurocysticercosis explains her simple partial seizure and headache, and she sadly has myocardial cysticercosis causing a dilated cardiomopathy, with resultant MR.

I think the key in managing this case is going to be sensitively informing her of the bad news and uncertain prognosis before slapping her on some steroids and anti-helminthics.

I know some people would go ahead and do bloods, imaging, or muscle biopsies, but I’m pretty confident, as after all 97% of the diagnosis comes from the history and physical examination.

This is bread and butter medicine, probably a couple of these on every take.

Can I smoke that cigar now? (It’s a fat Montecristo, by the way)

Josh

I did enjoy the pulmonary hypertension reference: had you considered that the sildenafil (viagra for our more junior readers) could be part of a clinical trail in its use in the treatment of pulmonary hypertension. Bosantin is more en vouge at the minute I suppose.

All that talk is interesting but its not the diagnosis. Anything else this could be?

This woman is 32, and childless. She thinks that being thinner will attract a mate, and this is why she is taking the perilous combination of phentermine and fenfluramine to facilitate rapid weight loss.

The resultant primary pulmonary hypertension is causing the soft systolic murmur due to TR (and perhaps a Graham-Steele murmur as well that wasn’t noticed initially).

The headache is probably due to the sildenafil she is taking to make the artificial insemination methods more enjoyable. Or maybe the clomiphene to get those ageing ovaries working harder.

And the neuro symptoms – well, it’s probably just anxiety about her impending life of barren singleness with only cats for company.

I would prescribe paracetamol (naturally) as well as large regular doses of diazepam to be continued indefinitely, which I believe is the appropriate first line therapy to treat her anxiety.

(yet again, I hope nobody from the GMC is reading this)

Josh

Hepatitis B/C
HIV
Chlamydia

J

send for the psychiatrist

alteratively send for homeopathy

nothing else to be done