Physician's Assistant

Patient Details

Refined clerking (239 days ago 07:23)

Refined clerking Sun 10 August 2025 07:23

Last Modified: 239 days ago

MRN:

Content:

Medical ST4 Miller Clerking

Presenting Complaint:
Fall and confusion for 1 day

History of Presenting Complaint:
This 91-year-old gentleman presented following a fall at home yesterday evening. He was standing in the living room when he fell backwards, hitting his head on an armchair before landing on the carpet. His wife was present and managed to partially break his fall by holding onto his dressing gown belt. He sustained a minor occipital abrasion.

His wife reports that he has been increasingly confused and unsteady over the past 2-3 weeks, which is worse than his baseline cognitive state. She describes episodes of disorientation and believes he may have been confused prior to this fall. Following the fall, he became very confused and disoriented in time, place, and person with confused, delirious speech.

He experienced a similar episode of confusion which was short-lived approximately 5 weeks ago. He has had two falls this year and his mobility has been declining. He recently was using a walking frame and now relies on a stairlift.

His wife reports he has been having swallowing difficulties for the past 3 weeks, particularly with liquids. She also notes symptoms suggestive of prostatism with nocturia.

There have been no recent illness symptoms, no coryzal symptoms, cough, dyspnoea, chest pain, abdominal pain, fevers, rigors, vomiting, or diarrhoea.

Past Medical History:
• Atrial fibrillation (2023)
• Angina pectoris (1993)
• Benign essential hypertension (2005)
• Pre-diabetes (2021)
• Right inguinal hernia - repaired 2019, recurrent
• Left inguinal hernia - repaired 1993
• Bilateral cataracts - treated 2014
• Constipation
• Previous squamous cell carcinoma
• Solar keratosis

Drug History:
• Apixaban 2.5mg PO BD
• Bisoprolol 2.5mg PO OD
• Lisinopril 10mg PO ON
• Isosorbide mononitrate 40mg MR PO OD
• Simvastatin 10mg PO ON
• GTN spray 400mcg SL PRN

Allergy History:
• Edoxaban - headaches and dizziness

Social History:
Lives with his wife in a house with stairs. Previously worked in customer service. Drinks wine occasionally. Never smoked. Has a medical alarm system.

On Examination:
General Appearance: 91-year-old male, confused and disoriented, AMT4 0/4
Observations: HR 97/min, BP 201/111 mmHg, Temp 36.5°C, RR 15/min, O2 sats 98% on air
• Neurological: GCS 14/15, no clear focal neurological deficit, good power in all four limbs, no cranial nerve palsy on brief examination, confused and delirious but not dysarthric.
• Cardiovascular: Heart sounds normal, mild pedal oedema to mid-shin bilaterally
• Respiratory: Chest clear anteriorly
• Abdomen: Soft and non-tender, no palpable bladder
• Other: Calves soft and non-tender, minor occipital abrasion

Investigations:
• Blood tests: Neutrophilia, CRP 2
• CT Head: No acute intracranial pathology. No thromboembolic large vessel occlusion. C-spine no acute traumatic injury identified.

Impression:
Acute delirium likely multifactorial:
- Acute admission
- Post-traumatic HI
- Hypertensive encephalopathy
- Possible urinary retention
Worsened mobility, swallowing 3 weeks ago - ? CVA at that time

Management Plan:
1. Confusion screen bloods including B12, folate, TFTs
2. Speech and language therapy assessment for swallowing difficulties
3. Chest X-ray
4. MSU and blood cultures
5. MRI head
6. Antihypertensives
7. Bladder scanning +/- catheter
8. Dress and clean head wound please
9. TEP DNAR

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Refined clerking (239 days ago 07:21)

Refined clerking Sun 10 August 2025 07:21

Last Modified: 239 days ago

MRN:

Content:

Medical ST4 Miller Clerking

Presenting Complaint:
Fall with confusion for 1 day

History of Presenting Complaint:
This 91-year-old gentleman presented following a fall at home this evening. He fell backwards from standing height, hitting his head on a chair before landing on carpet. His wife partially broke the fall by holding his dressing gown belt. Following the fall, he became acutely confused and disorientated in time, place and person.

His wife reports increasing confusion and unsteadiness on his feet over the past few weeks. He has fallen multiple times this year. Three weeks ago, he experienced facial droop on one side but was able to raise both arms and quickly became lucid again - no stroke was confirmed at that time.

Over the past three weeks, he has also developed swallowing difficulties and is using a straw. His wife notes he is drinking less water and has been choking more frequently. He experiences significant nocturia but denies other urinary symptoms.

No recent illness, cough, dyspnoea, chest pain, abdominal pain, fevers, rigors, vomiting or diarrhoea.

Past Medical History:
• Atrial fibrillation (2023)
• Mild frailty (2024)
• Falls - multiple this year (2024)
• Angina (1994)
• Benign essential hypertension (2005)
• Right inguinal hernia - repaired 2019
• Left inguinal hernia - repaired 1993
• Bilateral cataract surgery (2014)
• Pre-diabetes (2021)
• Raised PSA (2017)
• Previous squamous cell carcinoma (2005)

Drug History:
• Apixaban 2.5mg PO BD
• Glyceryl trinitrate 400micrograms/dose sublingual spray PRN
• Bisoprolol 2.5mg PO OD
• Isosorbide mononitrate 40mg MR PO OD
• Lisinopril 10mg PO nocte
• Simvastatin 10mg PO nocte

Recently Stopped Medications:
• Edoxaban - stopped due to headaches and dizziness

Allergy History:
• Edoxaban - headaches and dizziness

Social History:
Lives with wife in a house with stairs
Mobility usually with walking frame, can manage short distances independently
No formal carers but wife provides support
Occupation: Retired customer service worker
Smoking: Never smoked
Alcohol: Small amount of wine occasionally
Functional Status: Struggling with stairs, increased assistance needed

On Examination:
General Appearance: Confused, delirious elderly gentleman
Observations: BP 201/111mmHg, HR 97/min, RR 15/min, O2 sats 98% on air, Temperature 36.5°C

• Neurological: AMT 0/4, confused and disorientated. Good power in all four limbs. No cranial nerve palsy on brief examination. No lateralising neurology. PERL
• Cardiovascular: Heart sounds normal, mild pedal oedema to mid-shin bilaterally, calves soft and non-tender
• Respiratory: Chest clear anteriorly
• Abdomen: Soft and non-tender, no palpable bladder
• Other: Minor occipital abrasion. Has urinated slightly in bed

Investigations:
• CT Head (10/08/2025): No injury to brain or bleeding
• Blood tests (10/08/2025): Slightly raised markers of infection

Impression:
Delirium of uncertain cause, possibly secondary to infection
Differential Diagnoses: Urinary tract infection, chest infection, possible stroke 3 weeks ago
Falls secondary to delirium and frailty

Management Plan:
1. Admit to medical ward for monitoring
2. Confusion screen bloods including B12, folate, TFTs, calcium
3. Chest X-ray to exclude pneumonia
4. MSU for microscopy and culture
5. Septic screen including blood cultures
6. Start empirical antibiotics for presumed infection
7. Bladder scan and catheterise if in retention
8. Consider MRI head to exclude recent stroke if no improvement
9. Speech and language therapy assessment for swallowing
10. Physiotherapy assessment when medically stable
11. Occupational therapy assessment for home safety
12. Medical Bed
13. Escalation plan: Ward-based care only given frailty and current quality of life

Field Clipboard (for EPR paste)

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Summary:

Investigations: