Physician's Assistant

Refined clerking Wed 06 August 2025 01:06

Last Modified: 243 days ago

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Medical ST4 Miller Clerking

Presenting Complaint:
Fall with head injury following recent craniotomy

History of Presenting Complaint:
Patient presented to A&E following a fall from toilet with head injury. She reports feeling increasingly weak over the past day or two. The fall occurred in the context of recent neurosurgical intervention for intracranial tumour. Patient has a history of craniotomy performed on 30th June 2025 for right parietal tumour resection. The underlying diagnosis was initially uncertain between glioblastoma and lymphoma, diagnosed 23rd June 2025. Patient reports difficulty sleeping in hospital environment. She denies any neck pain on examination. No current urinary or bowel symptoms. No cough or cold symptoms reported.

Past Medical History:
• Elective right parietal craniotomy for tumour resection - Glioblastoma 30/06/2025
• Essential hypertension

Drug History:
• Levetiracetam 1g PO BD
• Dexamethasone 2mg PO OD
• Lansoprazole 30mg PO OD (whilst on dexamethasone)
• Levetiracetam 500mg PO BD
• Beconase Aqueous 50mcg BD (both nostrils)
• Amlodipine 5mg PO ON

Allergy History:
• NKDA

On Examination:
General Appearance: Alert, oriented but reporting weakness
Observations: HR 61 bpm, BP 118/68 mmHg, Temp 37.3°C, RR 15/min, O2 sats 98% on air, ACVPU: Alert
• Neurological: Able to move all limbs. No neck tenderness on palpation. Cranial nerves not formally assessed
• Cardiovascular: Regular rhythm, no murmurs audible
• Respiratory: Clear chest on auscultation bilaterally
• Skin: Normal perfusion
• Urological: Passed urine within 6 hours

Investigations:
• Blood gas: pH 7.436, sodium 134, glucose 6
• ECG: Sinus rhythm, rate 72 bpm
• CRP 14, Creatinine 43 (baseline), INR 1.8
• White cells 13.4, Neutrophils 12.3
• CT head without contrast (06/08/2025): Surgical cavity in right parietal lobe with severe surrounding vasogenic oedema, mass effect with midline shift and transtentorial herniation. No intracranial haemorrhage

Impression:
Progression of glioblastoma multiforme with significant cerebral oedema causing mass effect and herniation

Management Plan:
1. High dose dexamethasone 8mg IV for 48 hours with PPI cover
2. Continue Levetiracetam for seizure prophylaxis
3. CT cervical spine to exclude neck injury following fall
4. Neurosurgical review completed - confirmed GBM progression
5. Admit under oncology team for further management
6. Not suitable for further neurosurgical intervention
7. Oncology bed required
8. Escalation plan to be discussed with oncology team regarding ceiling of care

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Refined clerking Wed 06 August 2025 01:06

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