Physician's Assistant

Patient Details

Refined clerking (89 days ago 07:58)

Refined clerking Wed 07 January 2026 07:58

Last Modified: 89 days ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Intracranial haemorrhage

History of Presenting Complaint:
Patient presented with acute onset left-sided neurological symptoms. Imaging revealed a right-sided intracerebral haemorrhage with associated left-sided weakness. Previous strokes documented with small vessel disease likely related to atrial fibrillation. Currently on anticoagulation with rivaroxaban for irregular heartbeat. Last dose of rivaroxaban taken approximately 24 hours ago (yesterday morning around 7-8am). Small amount of intraventricular extension noted on imaging with minimal surrounding oedema.

Past Medical History:
• Previous strokes with small vessel disease
• Atrial fibrillation (irregular heartbeat)
• Previous small strokes visible on historical imaging

Drug History:
• Rivaroxaban [dose not specified] PO [frequency not specified] - for atrial fibrillation
• Other medications mentioned but not specified

Allergy History:
Unknown

Social History:
Lives with family members who are present for consultation.

On Examination:
Left-sided neurological symptoms consistent with right cerebral hemisphere pathology affecting motor control of arms and legs.

Investigations:
• CT Head (26/01/26): Right-sided intracerebral haemorrhage with small intraventricular extension and minimal surrounding oedema. No evidence of old bleeding - all appears acute within last few hours.

Impression:
Acute right-sided intracerebral haemorrhage with intraventricular extension
Differential Diagnoses: Anticoagulant-related bleeding vs small vessel malformation vs haemorrhagic transformation of previous infarct
Secondary issues: Atrial fibrillation requiring anticoagulation balance

Management Plan:
1. Urgent blood pressure control and monitoring
2. Reverse anticoagulation - contact haematologist for rivaroxaban reversal agent
3. Neurological observations for deterioration (particularly first 24-48 hours)
4. Neurosurgical referral to Derriford for assessment (surgical intervention unlikely due to deep location)
5. Review all medications and adjust as appropriate
6. Monitor for clinical deterioration over next 24-48 hours when swelling may worsen
7. Stroke unit bed
8. Escalation plan to be discussed with family regarding ceiling of care

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Refined clerking (89 days ago 08:25)

Refined clerking Wed 07 January 2026 08:25

Last Modified: 89 days ago

MRN:

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

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: