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Patient Details

Refined clerking (87 days ago 04:52)

Refined clerking Fri 09 January 2026 04:52

Last Modified: 87 days ago

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Medical ST5 Miller Review
09/01/2026 05:00

Thanks for referring this gentleman to medicine following a fall and with a CT showing a haemothorax.

I was told that he has had progressive shortness of breath prior to his fall but he completely denies this.

Presenting Complaint:
Fall at home

History of Presenting Complaint:
Elderly gentleman presented to A&E following a fall at his daughter's house. He tripped on a small step, hit the wall, and fell straight onto his back. No loss of consciousness.

For the past 2-3 weeks, he has been experiencing a dull ache on the right side of his chest extending to the right upper abdomen. The pain is intermittent and always associated with wearing an overly tight jersey. Pain is not exacerbated by walking short distances (approximately 20 paces from bungalow to car) and does not cause breathlessness. No associated respiratory symptoms.

Social History:
Lives in a bungalow with his son. Independent with activities of daily living including washing, dressing, and laundry. Has cleaner once weekly for 2 hours. Shares shopping responsibilities with his son. Still drives daily.

On Examination:
• Normal chest sounds on auscultation
• Tenderness on palpation over right posterior chest wall, no tenderness on left side.

Impression:
Probable haemothorax following fall in a fit 85 year-old

Suggest:
Surgical discussion to consider admission under them for chest trauma
Hold edoxaban

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Refined clerking Fri 09 January 2026 04:52

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