Physician's Assistant

Patient Details

Refined clerking (55 days ago 17:22)

Refined clerking Tue 10 February 2026 17:22

Last Modified: 55 days ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Fall with knee injury and syncope

History of Presenting Complaint:
Patient attended eye department appointment at hospital. Whilst walking to car park through Women's Department, slipped on muddy ground and fell directly onto right knee. Sustained immediate pain and swelling to right knee with inability to bend knee due to pain, though able to straighten leg. Developed extensive bruising from proximal tibia and fibula to lower femur.

Whilst in ED awaiting assessment, patient experienced sudden blurred vision followed by loss of consciousness whilst sitting in wheelchair. Episode not witnessed by husband or staff. Patient regained consciousness spontaneously, feeling completely lucid with no post-ictal confusion. No chest pain, palpitations or shortness of breath prior to syncope. No preceding headache or focal neurological symptoms. Knee immobilised in brace whilst unconscious.

Patient had not eaten or drunk anything prior to episode. Was experiencing significant pain from knee injury at time of syncope. No previous similar episodes. Patient is primary carer for husband who has had previous strokes.

Past Medical History:
• Osteoarthritis
• Meniere's Syndrome (2004)
• Hypertension (2012)
• Subclinical Hyperthyroidism
• Essential Tremor (recently worsening, under investigation by GP)
• Gastro-Oesophageal Reflux Disease
• Bilateral hearing impairment (wears two hearing aids)

Drug History:
• Ferrous Gluconate 300mg PO OD
• Furosemide 40mg PO OD
• Adcal-D3 PO OD
• Pregabalin 75mg PO BD
• Laxido PO PRN
• Omeprazole 20mg PO OD
• Senna 7.5-15mg PO ON
• Naproxen 250mg PO TDS
• Primidone 375mg PO BD
• Lisinopril 10mg PO OD
• Paracetamol 1g PO PRN QDS

Allergy History:
Not documented

Social History:
Lives with husband in Bishop Sutton. Primary carer for husband who has had previous strokes. Previously lived on boats and travelled extensively in motor home around Europe. Retired. Previously worked in teaching. Active lifestyle prior to this injury.

On Examination:
Alert and fully lucid post-syncopal episode. Right knee immobilised in brace. Extensive bruising and swelling right knee extending from proximal tibia and fibula to lower femur. Laceration across knee. Unable to flex knee due to pain, able to extend. Hands show evidence of osteoarthritis with essential tremor noted. Abdomen soft and non-tender. Cardiovascular and respiratory examinations unremarkable. No focal neurological deficit identified.

Investigations:
• Right Knee X-ray (09/02/26): Comminuted fracture of patella with overlying soft tissue swelling and haematoma
• TSH 11.7 (previously 4.81) - T4 and T3 awaited
• Troponin T 16 (previously 21)
• FBC: Hb 119, white cells normal
• U&Es: Creatinine 88 (from 72), Sodium 133, Potassium normal, Urea 10.8
• Bone Profile: Corrected Calcium 2.62, Magnesium normal, remainder normal
• LFTs: ALT 38, remainder normal
• CRP 5
• Venous Blood Gas: pH 7.41, Sodium 133, Base Excess 1.7
• Cardiac monitoring: 12+ hours, no arrhythmias detected

Impression:
Comminuted fracture right patella
Syncope - likely vasovagal secondary to pain, reduced oral intake and potential hypovolaemia
Elevated TSH requiring follow-up

Management Plan:
1. Continue cardiac monitoring for 24 hours post-syncope as per current practice
2. Analgesia: Continue current regime of Naproxen and Paracetamol. Discussed Codeine but patient declines due to constipation concerns
3. Request CT Head to exclude intracranial pathology contributing to syncope
4. Orthopaedic review required to determine definitive management of comminuted patellar fracture - operative versus conservative management. Patient had difficulty understanding previous orthopaedic discussion due to hearing impairment and background noise. Clear communication required regarding treatment options
5. Fracture clinic follow-up as arranged by orthopaedics
6. GP follow-up for elevated TSH once T4 and T3 results available
7. Encourage oral fluids and nutrition
8. If observations stable and cardiac monitoring reassuring at 24 hours, consider discharge with orthopaedic follow-up plan
9. Ensure social care arrangements in place given patient is primary carer for husband
10. Write computer system note documenting assessment and plan
11. Update patient and family with clear management plan

Field Clipboard (for EPR paste)

Builds copy buttons from the headings currently in the note, and also lets you copy the entire note.

Summary:

Investigations:

Tasks

Feedback

• Collateral history: Consider obtaining more detailed witness account of syncope from ED staff who were present - duration of LOC, any jerking movements, colour changes, or tongue biting would help differentiate vasovagal from other causes
• Postural blood pressures: Given combination of antihypertensives (Lisinopril, Furosemide) and syncope, postural BP measurements would strengthen vasovagal diagnosis and identify orthostatic hypotension as contributing factor
• Medication review: Patient on both Furosemide and Lisinopril with rising creatinine (72→88) - consider if dehydration/medication contributed to syncope and whether dose adjustment needed
• Safety netting: Provide clear written instructions about red flag symptoms requiring re-attendance (further syncope, chest pain, palpitations, neurological symptoms) especially given patient's hearing impairment
• Social circumstances: Patient is primary carer for husband with stroke history - more detailed assessment of husband's care needs and contingency planning during patient's recovery period would be valuable
• Communication: Excellent rapport building and patient-centred approach with good attention to hearing difficulties, but ensure orthopaedic team aware of communication needs for consent discussions
• Thyroid management: Rising TSH and worsening tremor suggest thyroid dysfunction may be contributing to overall clinical picture - consider if urgent endocrine input needed rather than just GP follow-up

Refined clerking (55 days ago 17:42)

Refined clerking Tue 10 February 2026 17:42

Last Modified: 55 days ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Fall with knee injury and syncope

History of Presenting Complaint:
Patient presented to ED following a fall outside the hospital eye department. She was attending an ophthalmology appointment and whilst walking to the car park through the women's department, she trod on something slippery. Her shoe became covered in mud and she fell, landing directly on her right knee.

Whilst in ED awaiting assessment, patient experienced an episode of syncope whilst seated in a wheelchair. She reported her vision becoming blurry prior to losing consciousness. She regained consciousness spontaneously and felt completely lucid afterwards with no ongoing symptoms. She had not eaten or drunk anything prior to the episode. Patient was in significant pain from the knee injury at the time of the syncope.

No chest pain, shortness of breath, or other concerning symptoms prior to or following the syncopal episode. No previous similar episodes. Patient has essential tremor which has reportedly worsened recently and is under investigation by her GP.

Patient's husband has had recent strokes and she is his primary carer. Husband was admitted to hospital overnight separately which caused additional stress.

Past Medical History:
• Osteoarthritis
• Meniere's syndrome (2004)
• Hypertension (2012)
• Subclinical hyperthyroidism
• Essential tremor
• Gastroesophageal reflux disease
• Osteoarthritis right knee

Drug History:
• Ferrous gluconate 300mg PO OD
• Furosemide 40mg PO OD
• AdCal-D3 PO OD
• Pregabalin 75mg PO BD
• Laxido PRN
• Omeprazole 20mg PO OD
• Senna 7.5-15mg PO ON
• Naproxen 250mg PO TDS
• Primidone 375mg PO BD
• Lisinopril 10mg PO OD
• Paracetamol 1g PO QDS PRN

Allergy History:
Not documented

Social History:
Lives in Bishop's Stanton. Primary carer for husband who has had strokes. Previously lived on boats and travelled extensively in motor home around Europe. Wears two hearing aids and has difficulty with accents in noisy environments. Independent prior to this admission. Alcohol and smoking history not documented.

On Examination:
Alert, comfortable at rest, wearing knee brace.
• Musculoskeletal: Right knee - significant swelling extending from proximal tibia and fibula to lower femur. Effusion present. Unable to bend knee due to pain but can straighten leg. Bruising noted.
• Hands: Evidence of osteoarthritis. Essential tremor noted.
• Cardiovascular: Examination unremarkable. No peripheral oedema.
• Respiratory: Chest clear
• Abdomen: Soft, non-tender, no masses
• Neurological: Alert and oriented. No focal neurological deficit

Investigations:
• Right knee x-ray (26/02/10): Comminuted fracture of patella with overlying soft tissue swelling and haematoma
• TSH: 11.7 (previously 4.81) - T4 and T3 awaited
• Troponin T: 16 (previously 21)
• T4: 13.2
• Corrected calcium: 2.62
• Remainder of bone profile: Normal
• Magnesium: Normal
• Creatinine: 88 (previously 72)
• Sodium: Normal
• Potassium: Normal
• ALT: 38, remainder of LFTs normal
• CRP: 5
• Urea: 10.8
• Hb: 119
• White cells: Normal
• Venous blood gas: pH 7.41, sodium 133, base excess 1.7
• ECG: Normal
• Cardiac monitoring (20 hours): No abnormalities detected

Impression:
Comminuted patella fracture
Multifactorial syncope secondary to pain, no oral intake, dehydration in hot ED environment

Differential Diagnoses:
Cardiac syncope - excluded by normal troponin, ECG and prolonged cardiac monitoring
Neurological cause - no focal signs, patient fully lucid post-event

Management Plan:
1. Observed for approximately 20 hours post-syncope with no further episodes
2. Eating and drinking well, feels much better
3. Analgesia: Continue naproxen and paracetamol for pain management. Patient declined codeine.
4. Orthopaedic follow-up: Fracture clinic appointment as arranged by T&O team
5. Discharge home today with safety-netting advice
6. Advise to return if further syncopal episodes or concerning features develop
7. GP follow-up if required for ongoing symptoms
8. Consider CT head if further syncopal episodes occur

Discharge Letter:
Miss Taylor presented following a fall outside our hospital onto her right knee. Subsequent x-ray demonstrated a patella fracture being followed up by the orthopaedic team in fracture clinic.

She experienced an episode of syncope in the emergency department. She was observed for circa 20 hours following this episode of syncope with no further concerning features. A panel of blood tests to investigate this was negative for a clear underlying cause. ECG was normal and cardiac monitoring was normal.

Therefore we have discharged her with GP follow-up if required for further symptoms. She is welcome to return to us if she has any further episodes of syncope or any concerning features. She will follow-up with the orthopaedic team regarding her patella fracture.

Field Clipboard (for EPR paste)

Builds copy buttons from the headings currently in the note, and also lets you copy the entire note.

Summary:

Investigations:

Tasks

Feedback

• Consider obtaining collateral history from ED staff who witnessed the syncopal episode - details about duration, colour change, movements, and post-ictal state would strengthen documentation
• Safety-netting could be more specific - advise patient on concrete red flags (e.g., further syncope, chest pain, palpitations, neurological symptoms) rather than generic "concerning features"
• Didn't establish baseline mobility or use of walking aids pre-injury - important for discharge planning given she's primary carer for husband
• Could have explored patient's concerns more systematically - she clearly struggled to understand orthopaedic team's explanation and has anxiety about caring responsibilities
• Consider documenting capacity assessment and consent for discharge given complexity of home situation
• Didn't clarify allergy status - important for complete medical record
• Could benefit from more detailed pain assessment using standardised scale and documenting impact on function
• Follow-up plan for elevated TSH not clearly communicated to patient - should ensure she understands GP will contact her regarding thyroid results