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Refined clerking (3 weeks ago 17:34)

Refined clerking Mon 16 March 2026 17:34

Last Modified: 3 weeks ago

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Medical ST5 Miller Clerking
Date: 26/03/2026, 17:34

Presenting Complaint:
Traumatic head injury and fall

History of Presenting Complaint:
An 89-year-old lady presented following a fall backwards down 7 carpeted steps. She was found at the bottom of the stairs. There was no loss of consciousness. She sustained an occipital head injury and reported posterior pelvic pain. She was unable to get up independently following the fall. She was visiting her daughter's address at the time of the incident.

She denied any pain at the time of assessment but was visibly in pain on moving around the bed. She has been feeling well in the days and weeks prior to the fall.

Past Medical History:
• Mixed cortical vascular dementia (diagnosed March 2026)
• Syncope and dizziness (March 2026)
• Stroke (2024)
• Glaucoma (2022)
• Atrial fibrillation (2018) - anticoagulated with rivaroxaban
• Hypothyroidism
• Hypertension

Drug History:
• Latanoprost 50 micrograms/mL eye drops 1 drop topically to both eyes at night
• Rivaroxaban 50mg PO OD
• Levothyroxine 50 micrograms PO OD (morning)
• Atorvastatin 40mg PO at bedtime

Allergy History:
• NKDA

Social History:
Living situation: Lives independently in a ground floor flat.
Mobility: Mobilises independently without a walking aid.
Functional Status: Manages her own shopping, finances, and other higher-order tasks independently.
Smoking: Non-smoker.
Alcohol: Does not drink.

On Examination:
Observations: HR 118 bpm (irregular, AF with rapid ventricular response), BP 136/73 mmHg, RR 13, O2 sats 99% on 4L oxygen (93% on air implied by supplemental requirement).
• Abdomen: Soft and non-tender on palpation.
• Cardiovascular: Irregular pulses. Oedema to mid-calf bilaterally. Normal heart sounds
• Respiratory: Clear chest on auscultation.

Investigations:
• TSH: 17.4
• Free T4: 14.8
• Magnesium: Normal
• Phosphate: Normal
• INR: 1.6
• WBC: 19.3 (neutrophils 16.56)
• Bone profile: Normal
• Creatinine: 109 (previously 95 on 04/02/2026; 89 on 28/08/2025)
• ALT: 48 (previously 14)
• AST: 45
• Amylase: 103
• CRP: 1
• Urea: 6.2
• Venous blood gas pH: 7.4
• CT Head and Trauma (full series): Shallow 4.6mm acute subdural haemorrhage in the falx cerebri. Large left-sided subgaleal haematoma without underlying skull fracture. Small left pleural effusion with tracheal secretions. Soft tissue injury in the right arm, possibly secondary to attempted cannulation. 11mm solid nodule at the right lung base - thought more likely to represent a discrete nodule than focal atelectasis; 3-month follow-up CT recommended if clinically indicated. No bony fracture identified. No visceral injury.

Impression:
Traumatic acute subdural haematoma.
AF with rapid ventricular response. 
Elevated WBC with neutrophilia secondary to trauma. 
Incidental right lung base nodule requiring follow-up. 
Elevated TSH suggesting poor compliance with thyroxine replacement

Management Plan:
1. Neurosurgical referral for observation and advice regarding traumatic subdural haematoma - for local observation
2. Reversal of DOAC with PCC - performed by ED team.
3. Stop rivaroxaban - consider switch to apixaban on discharge.
4. If heart rate does not settle following adequate analgesia, consider rate control for fast AF.
5. Admit for 24-48 hours of observation to ensure no deterioration.
6. Analgesia
7. Neuro obs
8. Three-month follow-up CT chest for incidental 11mm right lung base nodule - NOT REQUESTED
9. Escalation: For active full ward-based care. Not for CPR. DNACPR form completed August 2025.

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Refined clerking Mon 16 March 2026 17:34

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