The next patient is no problem take care bye sylvia bolt 583610 84 year old lady presenting complaint is difficulty passing urine history of presenting complaint multiple recent admissions over september and october most recently admitted on the 20 first 10/24/2005 following a fall from home with injury to her left wrist full stop also treated for delirium on background of dementia and urinary retention likely secondary to constipation full stop paragraph she was discharged home with you plan for fracture clinic follow-up following her wrist fracture full stop paragraph other admissions in october september relating to ongoing cognitive impairment and wrist fracture as well as urinary retention full stop paragraph now admitted with increased agitation for the last few days and the sensation that she needs to pass urine by only passing small amounts full stop has had treatment with fosfomycin in care home however not improved with this full stop paragraph no fevers and opening her bowels normally for her full stop paragraph in ed sylvia climbed out of bed and sustained a head injury full stop has some scalp bleeding on the left temporal occipital area with the ed team full stop ct head performed demonstrating subdural bleed with element of contusion and neurosurgery referral made however no result of this yet full stop <\n\n> Past medical history bcc <\n> Hip replacement 20 22 <\n> Osteoarthritis cataract ckd 3 obesity central hypertension total abdominal hysterectomy in 2000 and appendicitis in 2000 also diagnosis of cognitive impairment dementia mentioned on discharge summaries however not coded on gp record medications list paracetamol as required bisacodyl 5 mg 1 to 2 at night for relief of constipation citalopram 10 mg once a day glycerol suppositories 1 or 2 once a day lactulose 15 ml up to twice a day as required and civodyne 5 microgram per hour transdermal patches applying 1 per week that's fentanyl patch social history she lives in mount pleasant care home newton abbott paragraph add to the history of any complaint bladder scan was 390 ml in ed paragraph allergic history no known drug allergies on examination observations respiratory rate 15 oxygen saturation is 96% on air heart rate 84 blood pressure 154 over 91 temperature 36.6 news score of 3 due to her new confusion investigations crp of 1 her lefties normal urea normal sodium a 132 from a 136 in mid october creatinine 65 and patient's baseline full blood count normal ct head no acute intracranial pathology from the november 5 at 01:00 in the morning however repeat ct head and c spine at 10:00 in the morning demonstrating no acute fracture or dislocation in the c spine and the brain a small subdural hemorrhage along the superior falx at the vertex and small high anterior frontal contusion hemorrhages and we started could you just sit somewhere to find out a bit mhmm so you sit forward is it her did she slap well yeah until she became pregnant she used to find out yeah and it was like the space of 30 seconds for a long time yeah for the she the nurse on the phone's daughter yeah yeah at the time and then and then I'll bring her next door to the was so short time yeah what can you do yeah I'm fine okay and in terms delivery what's I guess the urinary retention that's so we've got tiny the same thing just this place this is the original over 2 minutes yeah I did glue that 1 0 okay and I did it I glued it because it was the weeping that way alright so everything's fine no worries I need to sort of see what I'm doing I'm just gonna get some I'm gonna get a cone which is some of air out of the way and then see exactly what I'm at and then and sure I have a choreographic trying to address it into a what do you think what do think you're do with that I'm sure okay guess and then that's again gonna go see this yeah what's your bill it's got a catheter it should bleed the catheter all it's a bleed bad I'll see what the neurosurgeon will say I think they'll say do nothing they'll probably say to be fair they'll probably say admit for 24 hours of abstinence I think she'll run it up to 80 a bit later sure and then we'll just treat her constipation and I think she should just have a long term and you know we can take it out in the 2 weeks time or whatever once we fix the constipation then we just give it to our patients but I'll let you sort them before we put them they they drained quite overnight didn't they I think that's $303,109 mils in the bladder but I haven't seen the notes so there was 320 in the bladder and then they drained 1000 900 off it when it was put in alright so she's having a decreased cast of diuresis and then she's had another 300 and another 800 so she's had lots fine so she was definitely pushing yeah in a chronic obstruction picture I can't wear a note sir they I think they're scattered on the desk that's there think a minute I'll do this for yeah about a 10 k yeah so then when I go up is that alright then I get back and then we'll do it at same time yeah okay alright that's alright thank you note the tap form elderly frail lady with moderate to significant decline not full escalation which I agree with the paramedic history treated with fosfomycin they are treating her for alzheimer's started memantine today so she has alzheimer's dementia hypertension ckd osteoarthritis high risk of falls so the plan is ed team to kindly dress and close head wounds if appropriate number 2 chasing neurosurgical review but unlikely for any acute intervention in this clinical context number 3 input output monitoring and replace 50% of losses if experiencing significant post catheter diuresis with crystalloid number next kidney function marnay to ensure not becoming biochemically dehydrated number next keep catheter until constipation confidently treated number next increase laxatives and give enema number next aim discharged home as soon as possible as delirium will be worsened in hospital environment impression is subdural hemorrhage secondary to head injury secondary to delirium secondary to acute urinary retention secondary to constipation