Physician's Assistant

Patient Details

Refined clerking (152 days ago 11:46)

Refined clerking Wed 05 November 2025 11:46

Last Modified: 152 days ago

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Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Difficulty passing urine

History of Presenting Complaint:
Multiple recent admissions over September and October 2024. Most recently admitted on 21/10/2024 following a fall at home with injury to her left wrist. Also treated for delirium on background of dementia and urinary retention likely secondary to constipation. She was discharged home with plan for fracture clinic follow-up following her wrist fracture.

Other admissions in October and September relating to ongoing cognitive impairment, wrist fracture, and urinary retention.

Now admitted with increased agitation for the last few days and the sensation that she needs to pass urine but only passing small amounts. Has had treatment with fosfomycin in care home after bladder scan only showing 90mls however not improved with this. No fevers and opening her bowels normally for her.

In ED, patient climbed out of bed and sustained a head injury with some scalp bleeding on the left temporal occipital area. CT head performed initially demonstrated subdural bleed with element of contusion and neurosurgery referral made.

Past Medical History:
• BCC
• Hip replacement 2022
• Osteoarthritis
• Cataract
• CKD stage 3
• Obesity
• Hypertension
• Total abdominal hysterectomy 2000
• Appendicectomy 2000
• Alzheimer's dementia (recently started memantine)

Drug History:
• Paracetamol PRN
• Bisacodyl 5mg 1-2 nocte for constipation
• Citalopram 10mg PO OD
• Glycerol suppositories 1-2 OD PRN
• Lactulose 15ml BD PRN
• Fentanyl 5 microgram/hour transdermal patches, 1 per week

Allergy History:
• NKDA

Social History:
Lives in Mount Pleasant Care Home, Newton Abbot. Elderly frail lady with moderate to significant decline (from TEP form). High risk of falls.

On Examination:
General Appearance: Confused, combative
Observations: RR 15, O2 sats 96% on air, HR 84, BP 154/91, Temp 36.6°C, NEWS score 3 due to new confusion
HS normal
Clear chest anteriorally
SNT abdomen - catheterised

Investigations:
• CRP 1
• Liver function tests: Normal
• Urea: Normal
• Sodium: 132 (was 136 in mid-October)
• Creatinine: 65 (patient's baseline)
• Full blood count: Normal
• CT head (05/11/24 01:00): No acute intracranial pathology
• CT head and C-spine (05/11/24 10:00): No acute fracture or dislocation in C-spine. Small subdural haemorrhage along the superior falx at the vertex and small high anterior frontal contusion haemorrhages
• Bladder scan: 390ml in ED, subsequently drained 1900ml when catheter inserted, then further 300ml and 800ml

Impression:
Worsening in delirium secondary to subdural haemorrhage secondary to head injury secondary to delirium secondary to acute urinary retention secondary to constipation

Management Plan:
1. ED team to dress and/or close head wounds with thanks
2. Chase neurosurgical review but unlikely for any acute intervention in this clinical context
3. Input/output monitoring and replace 50% of losses if experiencing significant post-catheter diuresis with crystalloid
4. Monitor renal function to ensure not becoming biochemically dehydrated
5. Keep catheter until constipation confidently treated - aim for outpatient TWOC
6. Increase laxatives and give enema
7. Aim discharge home as soon as possible as delirium will be worsened in hospital environment
8. Stool charting
9. Stop fentanyl patch - unclear indication, confused, constipated
10. TEP: Already completed - for ward-based care only and I agree with this

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Refined clerking Wed 05 November 2025 11:46

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