Physician's Assistant

Refined clerking Fri 28 November 2025 19:06

Last Modified: 129 days ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Collapse and confusion

History of Presenting Complaint:
This 89-year-old gentleman was well until this morning when he woke up fine and got dressed normally. He then developed what he described as the worst headache he had ever experienced. Later in the afternoon, whilst standing at the window, he collapsed and was found on the floor by his grandson who was working in the garden. He was unable to get up from the floor and appeared confused, asking questions like "how did I get here?" and "why haven't I been able to get up?". There was associated urinary incontinence and he has been noted to be mildly pyrexial. He appears to have weakness causing him to lean to the right side consistently. His son confirmed he sounded normal when spoken to over the phone this morning, indicating an acute onset.

Past Medical History:
• Hip problems (previous injury affecting mobility)
• Uses walking stick for mobility
• Independent living with stair lift installed

Drug History:
Unknown

Allergy History:
Unknown

Social History:
Lives independently in own home with stair lift installed. Usually very independent but uses a walking stick for mobility. Has family support from son and grandson who live nearby.

On Examination:
General Appearance: Alert, cooperative gentleman who appears unwell
Observations: BP 170/? systolic, mildly pyrexial
• Neurological: Glasgow Coma Scale appears intact - orientated to person and month (initially said November, corrected to August). Good bilateral hand grip strength. No obvious focal neurological deficit on formal testing. Cranial nerves II-XII grossly intact. No visual field defects. Facial symmetry normal. Upper and lower limb power appears symmetrical bilaterally. Finger-nose-finger test normal. Sensation intact to light touch. Tendency to lean to the right when sitting upright, described as feeling like being "on a ship". No obvious facial droop.
• Other systems: Not formally examined

Investigations:
CT head scan requested - pending

Impression:
Acute neurological event in 89-year-old gentleman
Differential Diagnoses: Stroke, intracranial haemorrhage, urinary tract infection with delirium, medication-related confusion, metabolic disturbance

Management Plan:
1. Urgent CT head scan to exclude intracranial pathology
2. Full blood count, urea and electrolytes, inflammatory markers, urinalysis
3. ECG and chest X-ray
4. IV access and baseline observations monitoring
5. Neurological observations 4-hourly
6. Consider antiplatelet therapy pending scan results
7. Medical ward admission for further investigation and monitoring
8. Escalation plan to be discussed with patient and family regarding resuscitation status

Field Clipboard (for EPR paste)

Builds copy buttons from the headings currently in the note, and also lets you copy the entire note.

Summary:

Investigations:

Refined clerking Fri 28 November 2025 19:06

Field Clipboard (for EPR paste)

Tasks

Feedback