Transcription - 20260107T 06-27.mp3

Rob you need to help to do it at moment I see I'm I'm 1 of the problems I've met someone before but not a few guys over good good yeah I'm rob and I'm another medical registrar so that's really I've just seen the result of your scan team now mhmm do you wanna talk a bit about the result with here with your family yeah is that alright yeah alright the scan shows that you've had a stroke yeah unfortunately it shows a bleed in the brain as a cause of the stroke as opposed to clot a in any vessel so there's a small bleed on the right hand side of the brain which is causing these left sided symptoms yeah alright there's a tiny bit of swelling around that bleed and you can see there's a small bleed into some of the ventricles which are in the blood left so at the moment the mainstay of what we need to do is get your blood pressure nicely under control and keep a really close eye on that your rivaroxaban that you're on we need to think about reversing that to stop you bleeding because that thins the blood obviously I've referred you to my colleagues in derriford who are the neurosurgeons I don't know much that they suggest an operation for this and it's important that they look at your pictures and make that decision for themselves so that's my current plan of what we're doing at the moment any questions like that paul how does the brain start awesome so your body will stop it by itself reversing the anticoagulation if we're able to do that will be an important step in helping the bleeding stop when there's blood in the brain irritates the brain and it causes symptoms to be worse in that initial phase it's very important to know how much effect that's had on that brain injury in an area of the brain that's normally associated with control of the arm's legs does that make sense why we're having symptoms only the first sort of as as the week progresses things can get a little bit worse and as swelling happens around the beat things can get slightly worse after that and usually get worse in the first sort of 34 to 38 hours we see it getting worse then usually it's better than normal so it's very difficult to say you know what the outcome will be in terms of what kind of function the amount of the end of this so her other medication other than the roxaban then should she be having that or yeah I'll have a look at all of her medicines and work out what to do and prescribe you more for her if she needs to sort you better thank you thank you very much I'm sorry sarah if you had a clot in your brain there's a treatment that we could send you off the wolf unfortunately with a bleed in the brain options our are limited that way we'll keep a really good eye on your blood pressure get that nicely under control and reverse that anticoagulation to stop you from bleeding not a problem sorry he's calling me he there can be called an ambulance so sometimes you can have a small stroke and then that you can bleed into that because if the stroke exposes blood vessels which can then bleed into that area that's a possibility obviously thinning the blood doesn't help because you're at more higher risk of stroke however in your context with the irregular heartbeat that you're having it massively decreases your risk so sometimes you get small vessels that are malformed in the brain too small for us to see on any scans that can burst spontaneously and bleed so is there a possibility of this bleeding happening since she had the most stroke while back no we see a fresh blood and no old bleeding this has all happened within the last few hours right it's possible that the previous strokes that she had had exposed the blood vessel in that area and it's more prone to bleeding if that makes sense yeah because she'd had some scans I was just looking at in the past that it's showing some small tiny strokes what we call small vessel disease probably related to the irregular heartbeat that we had before so we're just working on the exactly but as I say I don't think that they're going to suggest an operation for this it would involve them going quite deep into your brain so function after that would probably be worse but it's important that they look at the pictures and decide that I don't think an operation is what they'll suggest so when you give relaxed medications you really get a I need to speak to the haematologist on call to look at whether we have a reversal agent for this medicine we should have a reversal agent for the rivaroxaban to counteract its effects and make it look that have you got a list of the medication that she's on for me to give rivaroxaban I think I've got it on a computer but if I can't find it I'll be fine is that alright no problem did she take her rivaroxaban this morning no she hasn't had any of her medications sorry I'm I'm in night yeah yeah yesterday and they made a voroxaban yeah about 7 and 08:00 about 7 and 08:00 yesterday morning yes about about about over approaching 24 hours after correct thank you yeah okay good I'll then make a few calls and work out the reversal of this medicine and then she can come back to you with that and then I'll be on the phone call okay so if you have any questions I'll be around so if you'd like me to just grab a look okay so should we have her botox back yep the hematologist is 24 hours out and it's a literature okay main guideline okay and he I'm just used to it someone long well that's just my my husband's face he's just messing basically

Medical ST5 Miller Clerking

Presenting Complaint:
Intracranial haemorrhage

History of Presenting Complaint:
Patient presented with acute onset left-sided neurological symptoms. Imaging revealed a right-sided intracerebral haemorrhage with associated left-sided weakness. Previous strokes documented with small vessel disease likely related to atrial fibrillation. Currently on anticoagulation with rivaroxaban for irregular heartbeat. Last dose of rivaroxaban taken approximately 24 hours ago (yesterday morning around 7-8am). Small amount of intraventricular extension noted on imaging with minimal surrounding oedema.

Past Medical History:
• Previous strokes with small vessel disease
• Atrial fibrillation (irregular heartbeat)
• Previous small strokes visible on historical imaging

Drug History:
• Rivaroxaban [dose not specified] PO [frequency not specified] - for atrial fibrillation
• Other medications mentioned but not specified

Allergy History:
Unknown

Social History:
Lives with family members who are present for consultation.

On Examination:
Left-sided neurological symptoms consistent with right cerebral hemisphere pathology affecting motor control of arms and legs.

Investigations:
• CT Head (26/01/26): Right-sided intracerebral haemorrhage with small intraventricular extension and minimal surrounding oedema. No evidence of old bleeding - all appears acute within last few hours.

Impression:
Acute right-sided intracerebral haemorrhage with intraventricular extension
Differential Diagnoses: Anticoagulant-related bleeding vs small vessel malformation vs haemorrhagic transformation of previous infarct
Secondary issues: Atrial fibrillation requiring anticoagulation balance

Management Plan:
1. Urgent blood pressure control and monitoring
2. Reverse anticoagulation - contact haematologist for rivaroxaban reversal agent
3. Neurological observations for deterioration (particularly first 24-48 hours)
4. Neurosurgical referral to Derriford for assessment (surgical intervention unlikely due to deep location)
5. Review all medications and adjust as appropriate
6. Monitor for clinical deterioration over next 24-48 hours when swelling may worsen
7. Stroke unit bed
8. Escalation plan to be discussed with family regarding ceiling of care

Summary

Investigations

Plans

Medical ST5 Miller Clerking

Presenting Complaint:
Stroke with intracerebral haemorrhage

History of Presenting Complaint:
Patient presented with acute onset left-sided neurological symptoms. CT brain imaging revealed acute intracerebral haemorrhage on the right side of the brain causing left-sided weakness and symptoms. There is associated small amount of swelling around the bleed and minor intraventricular extension. Patient has background of atrial fibrillation on anticoagulation with rivaroxaban. Previous history of small vessel disease and prior minor strokes. Last dose of rivaroxaban taken yesterday morning at approximately 0700-0800 hours (approaching 24 hours prior to assessment).

Past Medical History:
• Atrial fibrillation - on anticoagulation
• Previous cerebrovascular accidents
• Small vessel disease

Drug History:
• Rivaroxaban [dose unknown] PO [frequency unknown] - last taken 06/01/26 0700-0800hrs
• Other medications present but not specified

Recently Stopped Medications:
• All regular medications withheld since admission

Allergy History:
Unknown

Social History:
Lives with family support present during consultation.

On Examination:
General Appearance: Alert, family present
Observations: Blood pressure elevated requiring control
• Neurological: Left-sided weakness secondary to right cerebral haemorrhage

Investigations:
• CT Brain (07/01/26): Right-sided intracerebral haemorrhage with minor surrounding oedema and small intraventricular extension. Evidence of previous small vessel disease changes

Impression:
Acute right-sided intracerebral haemorrhage with intraventricular extension
Secondary issues: Atrial fibrillation on anticoagulation, hypertension requiring control

Management Plan:
1. Urgent blood pressure control and monitoring
2. Reverse anticoagulation - haematology consultation for rivaroxaban reversal agent
3. Neurosurgical referral to Derriford for assessment (operation unlikely given deep location)
4. Close neurological monitoring for deterioration over next 24-48 hours
5. Review all medications and prescribe essential medications only
6. Patient and family education regarding diagnosis and prognosis
7. Stroke unit admission
8. Escalation plan to be discussed regarding appropriateness for intensive care

Summary

Investigations

Plans