Physician's Assistant

Refined clerking Wed 07 January 2026 08:25

Last Modified: 89 days ago

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Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Stroke with intracerebral haemorrhage

History of Presenting Complaint:
Patient presented with acute onset left-sided neurological symptoms. CT brain imaging revealed acute intracerebral haemorrhage on the right side of the brain causing left-sided weakness and symptoms. There is associated small amount of swelling around the bleed and minor intraventricular extension. Patient has background of atrial fibrillation on anticoagulation with rivaroxaban. Previous history of small vessel disease and prior minor strokes. Last dose of rivaroxaban taken yesterday morning at approximately 0700-0800 hours (approaching 24 hours prior to assessment).

Past Medical History:
• Atrial fibrillation - on anticoagulation
• Previous cerebrovascular accidents
• Small vessel disease

Drug History:
• Rivaroxaban [dose unknown] PO [frequency unknown] - last taken 06/01/26 0700-0800hrs
• Other medications present but not specified

Recently Stopped Medications:
• All regular medications withheld since admission

Allergy History:
Unknown

Social History:
Lives with family support present during consultation.

On Examination:
General Appearance: Alert, family present
Observations: Blood pressure elevated requiring control
• Neurological: Left-sided weakness secondary to right cerebral haemorrhage

Investigations:
• CT Brain (07/01/26): Right-sided intracerebral haemorrhage with minor surrounding oedema and small intraventricular extension. Evidence of previous small vessel disease changes

Impression:
Acute right-sided intracerebral haemorrhage with intraventricular extension
Secondary issues: Atrial fibrillation on anticoagulation, hypertension requiring control

Management Plan:
1. Urgent blood pressure control and monitoring
2. Reverse anticoagulation - haematology consultation for rivaroxaban reversal agent
3. Neurosurgical referral to Derriford for assessment (operation unlikely given deep location)
4. Close neurological monitoring for deterioration over next 24-48 hours
5. Review all medications and prescribe essential medications only
6. Patient and family education regarding diagnosis and prognosis
7. Stroke unit admission
8. Escalation plan to be discussed regarding appropriateness for intensive care

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Refined clerking Wed 07 January 2026 08:25

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