Transcription - 20251105T 12-43.mp3

George moran '5 77 '6 5 '4 84 year old man past medical history subdural hematoma bilateral requiring burr holes october 2024 delirium on background of dementia october 20 '20 '4 vascular dementia may 2024 background diabetic retinopathy on the left left ventricular systolic dysfunction with an ejection fraction of 40 to 45% type 2 diabetes mellitus with background diabetic retinopathy tia in 2022 prostate cancer 2022 ckd 3 hypertension admitted in june 2025 with an acute on chronic subdural which he was observed for 24 hours before discharge back to his care home investigations using his normal ct head bilateral subdural collections again noted right 1.2 centimeters and left 1.3 centimeters at maximum depth both contain small high attenuation foci which suggests a more acute component of hemorrhage no hydrocephalus or midline shift appearance is broadly similar to previous study of june with slight reduction in size of the bilateral subdural collections chest x-ray increased pulmonary vasculature with possible small left pleural effusion suggestive of cardiac impairment no consolidation full blood count hemoglobin a 120 with mild monocytosis liver function test normal crp 7 urea 8.3 most recent h p a 1 c 38 back yesterday medications list atorvastatin 20 mg each day laxido as required folic acid 5 mg once a day brinzolamide eye drops twice a day in both eyes latanoprost eye drops 1 drop to be used in both eyes after evening meal rinzolamide is 10 mg/ml and latanoprost is 50 micrograms per milliliter observations root rate 17 oxygen saturation is 98% on air pulse rate 87 blood pressure a 143 over 76 temperature 36.9 alert background vascular dementia he in social history lives in a care home mobilizes independently in the history of presenting complaint nursing star nurse care home staff say not being himself for the last few days more subdued on examination disoriented and confused not aware of where he is but very pleasantly so heart sounds normal right basal fine crepitations more than the left however present pattern actually abdominal examination soft and nontender with large reducible umbilical hernia no peripheral edema or rashes impression impression an acute on chronic subdural hemorrhage possibly due to fall unwitnessed in care home plan continue to hold clopidogrel number 2 neurosurgery referral number 3 admit for observation

Medical ST5 Miller Clerking

Presenting Complaint:
Generally unwell and off legs

History of Presenting Complaint:
Care home staff reported that George has not been himself for the last few days, appearing more subdued than usual. There was a possible unwitnessed fall in the care home.

Multiple previous admissions with fall and known chronic SDH.

Past Medical History:
• Bilateral subdural hematoma "requiring burr holes" October 2024
• Vascular dementia May 2024
• Diabetic retinopathy (left eye)
• Left ventricular systolic dysfunction with ejection fraction 40-45%
• Type 2 diabetes mellitus - latest HbA1c: 38 mmol/mol
• TIA 2022
• Prostate cancer 2022
• CKD stage 3
• Hypertension

Drug History:
• Atorvastatin 20mg PO OD
• Laxido PRN
• Folic acid 5mg PO OD
• Brinzolamide 10mg/ml eye drops BD both eyes
• Latanoprost 50mcg/ml eye drops 1 drop both eyes after evening meal
• Clopidogrel - held due to subdural hemorrhage

Allergy History:
NKDA

Social History:
Lives in care home
Mobilises independently
Formal care arrangements in place

On Examination:
General Appearance: Alert but disoriented and confused, not aware of where he is but pleasantly so
Observations: RR 17, O2 sats 98% on air, HR 87, BP 143/76, Temp 36.9°C
• Cardiovascular: Heart sounds normal, no peripheral oedema
• Respiratory: Right basal fine crepitations more than left
• Abdomen: Soft and non-tender with large reducible umbilical hernia
• Neurological: Disoriented and confused
• Other: No peripheral oedema or rashes

Investigations:
• CT Head: Bilateral subdural collections - right 1.2cm and left 1.3cm at maximum depth, both contain small high attenuation foci suggesting acute component of hemorrhage, no hydrocephalus or midline shift, slight reduction in size compared to June 2025
• Chest X-ray: Increased pulmonary vasculature with possible small left pleural effusion suggestive of cardiac impairment, no consolidation
• Hb 120
• Mild monocytosis
• LFTs normal
• CRP 7
• Urea 8.3

Impression:
Acute on chronic subdural hemorrhage possibly due to unwitnessed fall in care home

Management Plan:
1. Neurosurgery referral - but I doubt will add anything
2. Admit for observation for 24h and monitoring
3. Likely back to care home after this

Summary

Investigations

Plans