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Patient Details

Refined clerking (191 days ago 21:16)

Refined clerking Sat 27 September 2025 21:16

Last Modified: 191 days ago

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Medical ST5 Miller Clerking

Presenting Complaint:
Atrial fibrillation with fast ventricular response

History of Presenting Complaint:
This 94-year-old lady was recently admitted 20/08/2025 following a right tibial plateau fracture sustained after slipping and falling on a mat. No loss of consciousness occurred and it was an isolated injury. During this admission, she was found to have a low haemoglobin and was also treated for a urinary tract infection. She was transferred to community hospital for ongoing rehab but has now re-presented with atrial fibrillation and a fast ventricular rate.

No clear underlying infective trigger. No cough, LUTS, palpitations, chest pain.

Very hard of hearing with no hearing aids in situ. Challenging history secondary to hearing impairment and possibly an element of delirium secondary to acute illness.

Past Medical History:
• Atrial fibrillation (1980)
• Hypertension
• Asthma
• Hypercholesterolaemia
• GORD
• Emergency appendicectomy (1972)
• Right tibial plateau fracture (September 2025)

Drug History:
• Pantoprazole 40mg PO OD
• Sertraline 100mg PO OD
• Betahistine 8mg PO TDS
• Fostair inhaler 100/6 micrograms TT BD
• Atorvastatin 10mg PO OD
• Paracetamol
• Candesartan 4mg PO OD
• Etoricoxib 60mg PO OD - held due to recent AKI
• Ferrous fumarate 210mg PO EOD
• Senna 15mg PO ON
• Salbutamol inhaler 100 micrograms T INH PRN
• Doublebase gel topical BD

Allergy History:
• Diclofenac - "intolerance"
• Aspirin - "intolerance"

Social History:
Admitted in community hospital currently. Non smoker, no alcohol
Lives with husband
Stick outside, ET 100 yrds, no stairs.

On Examination:
Alert
Observations: HR 140 bpm, SP 140. SpO2 98% AIR. Afebrile.
• Cardiovascular: Irregular pulses, ECG atrial fibrillation with fast ventricular response
• Respiratory: Bilateral crepitations to the mid zones
• Abdomen: Soft, non tender
• Lower limbs: Right leg bruised but not erythematous, not hot to touch. Very mild pedal oedema
• Other: Catheter in situ

Investigations:
• INR 1.1
• Calcium: Normal
• ALP: 137
• ALT: Haemolysed
• AST: Haemolysed
• Sodium: 131 (previously 130 in August)
• Creatinine: 58 (at baseline)
• TSH: 1.32
• CRP: 6
• Haemoglobin: 104 (previously 68 in August, 87 in September)
• Platelets: 145
• Transferrin saturation: 10%
• Urine MC&S (13/09/2025): E. coli, susceptible to amoxicillin, fosfomycin and nitrofurantoin

Impression:
Atrial fibrillation with fast ventricular response
Unclear underlying trigger - recent hospitalisation, pain secondary to fracture +/- electrolyte abnormalities may contribute
Clinically mildly overloaded - no further IVI planned

Management Plan:
1. IV Digoxin loading dose for rate control (second dose as rate still not controlled), then 125mcg daily once rate controlled
2. Add magnesium to blood tests and replace if low
3. Chest X-ray
4. Transfer to hospital bed
5. Further discussion regarding risk benefit of anticoagulation for atrial fibrillation when patient more settled
- Note longstanding history of AF and not anticoagulated.
6. AMU
7. Discharge back to community hospital once rate controlled
8. IO monitoring
9. Stop statin for primary prevention at 94.

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Refined clerking Sat 27 September 2025 21:16

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