Physician's Assistant

Patient Details

Refined clerking (129 days ago 22:53)

Refined clerking Fri 28 November 2025 22:53

Last Modified: 129 days ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Falls with weakness

History of Presenting Complaint:
This 89-year-old gentleman was found collapsed on the floor by his grandson this afternoon.

He reported that his legs felt weak and he was unable to pull himself up using the radiator. Initial concern was raised regarding possible stroke given reported right-sided weakness, however this resolved by the time of assessment. He has been experiencing general malaise, shivers, dry cough and feeling unwell for several days. He had discontinued his apixaban for 2 days due to bruising on his arm. Ambulance crew documented fever on arrival. He reports occasional headaches but none currently. Denies dysuria. No chest pain or shortness of breath .

Past Medical History:
• Gout
• Osteoporosis  
• Atrial fibrillation
• Prediabetes
• Chronic lymphocytic leukaemia
• Sleep apnoea (2004)
• Hypothyroidism
• Hypertension

Drug History:
• Levothyroxine 125 micrograms PO OD
• Allopurinol 100mg PO OD
• Adcal-D3 PO BD
• Alendronic acid 70mg PO weekly
• Bisoprolol 1.25mg PO OD
• Ramipril 2.5mg PO OD
• Apixaban 5mg PO BD

Recently Stopped Medications:
• Apixaban - stopped 2 days ago due to arm bruising

Allergy History:
• NKDA

Social History:
Lives independently. Family support available - grandson involved in care. Mobile around hospital between bed and CT scanner, though required assistance from 2 ambulance personnel initially.

On Examination:
General Appearance: Alert, appears unwell, tall gentleman uncomfortable on trolley
Observations: Afebrile at time of examination (previous fever documented by ambulance crew)
• Tongue: Normal appearance
• Abdomen: No tenderness reported
• Neurological: No focal neurological deficits, no weakness , facial droop resolved

Investigations:
• CRP: 11
• CT Head: No acute intracranial pathology
• TSH: 0.16 with normal free T4
• WBC: 17.1, Neutrophils: 9.31, Lymphocytes: 6.38
• Ferritin: 507
• B12 and folate: Normal
• Calcium: Normal
• U&Es: Normal
• LFTs: Bilirubin 25 (intermittently raised previously, consistent with Gilbert's syndrome)
• INR: 1.1
• Magnesium: Normal
• Urea: Normal
• Venous blood gas: Normal

Impression:
Viral illness ? Flu with associated fall secondary to general weakness
vs CAP or UTI

Management Plan:
1. Chest X-ray
2. Mobility assessment - trial of mobilisation 
3. Consider overnight admission for observation given age and social circumstances if mobility poor
4. Restart apixaban
5. Flu swab
6. Urine MCS

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Patient Details

Refined clerking Fri 28 November 2025 22:53

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