Transcription - 20260316T 16-54.mp3

Rosa sloan 150170 89 year old lady and you married everything know yourself yeah note to temp form august 2025 for active full base care but not it or cpr social history lives independently ground floor flat does her own shopping was driving recently but does not drive anymore does her own finances and other higher order tasks as well investigations tsh17.4 with t414.8 magnesium normal phosphate normal coagulation screen inr 1.6 note on rivaroxaban ct head and trauma full series shallow 4.6 millimeter acute subdural hemorrhage in the falx cerebri large left sided subglial hematoma but without underlying skull fracture small left pleural effusion and tracheal secretions soft tissue injury in the right arm possibly due to attempted cannulation and subtle findings in the body of the report notably in the thorax 11 millimeter solid nodule in the right base which could represent focal atelectasis but thought more likely discrete nodule consider 3 month follow-up ct if indicated no fracture of the bones no visceral injury full blood count white cells 19.3 with neutrophils 16.56 but otherwise normal bone profile normal eosinase creatinine 9 from previously 95 on the february 4 and 89 on the 08/28/2025 lfts alt 48 up from 14 but otherwise normal amylase 103 crp of 1 urea 6.2 ast 45 venous blood sph 7.4 fall backwards down 7 steps carpeted found at bottom no loss of consciousness but unable to get up occipital head injury and posterior pelvic pain on scene background of cortical vascular dementia and mixed dementia march 2026 syncope dizziness stroke 2024 glaucoma 2022 atrial fibrillation 2018 for which she's anticoagulated with rivaroxaban hypothyroidism hypertension medications list latanoprost 50 mg micrograms per milliliter eye drops 1 drop to be used at night in both eyes rivaroxaban 50 mg once per day levothyroxine 50 micrograms once in the morning atorvastatin 40 mg at bedtime observations heart rate 118 so that's 99 on air on 2 l 4 l of oxygen respiratory rate 13 and blood pressure 136 over 73 ecg atrial fibrillation with a rapid ventricular response possible atrial flutter with a rapid ventricular response maybe 1 that's 86 just like you too young hi rosa I'm rob again in training I've had a chat to my colleagues and they think they'll be really best looked after by me so we're hoping to bring you to hospital just to keep an eye on this for you because you're going to be and you're fine we just keep you in for 24 to 48 hours okay how you're doing we make sure it's not getting any worse we're keep it both at home for that time and always go and get back to the house sounds good okay so I'm intrigued and and you live in is it a flat or a house too much today I have to work I read before it was a flat but I think I got a single address no I don't remember that from you I'm not fax out but he's asking me okay like a lotcher no no it's like a flat okay okay fine so it's a ground floor flat in the bed and in both the stairs you fell down after her place or you fall down some different stairs I'm fine with the water I'm fine for the last few days and weeks yes good yeah I'm not sure always stop yeah right I know what you mean are you allergic to anything no no medicines or anything like that no do you drink or smoke no not really your thing I don't smoke daughter and you walk out of the house without any assistance by yourself you don't use a frame or a stick no no and you were going around your daughter's just for a social visit I'm not sure if you're at it we're gonna take a look at 1 of those things yeah can I have a quick look at you do you mind I'm gonna go take this phone thank you you don't have to take anything off nice regular pulses you need me to sit forward for me anything only if it won't hurt you nice clear chest that's fine you can rest back if you feel that okay yep the heart's going a little bit fast are you in pain sure mhmm your heart's going a little bit fast are you in pain today no no nothing like that good I think 1 test 1 time yeah so edema to your midcar yeah lovely I touch your tummy yeah fine soft no pain no that's fine thank you for letting me do all of that malarkey we'll get you some good painkillers we'll get you back to bring you into hospital keep a close eye okay good any questions anything I've forgotten you're happy yes good see you soon so impression traumatic subdural hematoma plan neurosurgical advice as per neurosurgical referral for observation and for reversal of doac which has been performed by the ed team with pcc stop rivaroxaban if heart rate does not settle following analgesia consider rate control for fast atrial fibrillation number next consider switch to apixaban on discharge

Medical ST5 Miller Clerking
Date: 26/03/2026, 17:34

Presenting Complaint:
Traumatic head injury and fall

History of Presenting Complaint:
An 89-year-old lady presented following a fall backwards down 7 carpeted steps. She was found at the bottom of the stairs. There was no loss of consciousness. She sustained an occipital head injury and reported posterior pelvic pain. She was unable to get up independently following the fall. She was visiting her daughter's address at the time of the incident.

She denied any pain at the time of assessment but was visibly in pain on moving around the bed. She has been feeling well in the days and weeks prior to the fall.

Past Medical History:
• Mixed cortical vascular dementia (diagnosed March 2026)
• Syncope and dizziness (March 2026)
• Stroke (2024)
• Glaucoma (2022)
• Atrial fibrillation (2018) - anticoagulated with rivaroxaban
• Hypothyroidism
• Hypertension

Drug History:
• Latanoprost 50 micrograms/mL eye drops 1 drop topically to both eyes at night
• Rivaroxaban 50mg PO OD
• Levothyroxine 50 micrograms PO OD (morning)
• Atorvastatin 40mg PO at bedtime

Allergy History:
• NKDA

Social History:
Living situation: Lives independently in a ground floor flat.
Mobility: Mobilises independently without a walking aid.
Functional Status: Manages her own shopping, finances, and other higher-order tasks independently.
Smoking: Non-smoker.
Alcohol: Does not drink.

On Examination:
Observations: HR 118 bpm (irregular, AF with rapid ventricular response), BP 136/73 mmHg, RR 13, O2 sats 99% on 4L oxygen (93% on air implied by supplemental requirement).
• Abdomen: Soft and non-tender on palpation.
• Cardiovascular: Irregular pulses. Oedema to mid-calf bilaterally. Normal heart sounds
• Respiratory: Clear chest on auscultation.

Investigations:
• TSH: 17.4
• Free T4: 14.8
• Magnesium: Normal
• Phosphate: Normal
• INR: 1.6
• WBC: 19.3 (neutrophils 16.56)
• Bone profile: Normal
• Creatinine: 109 (previously 95 on 04/02/2026; 89 on 28/08/2025)
• ALT: 48 (previously 14)
• AST: 45
• Amylase: 103
• CRP: 1
• Urea: 6.2
• Venous blood gas pH: 7.4
• CT Head and Trauma (full series): Shallow 4.6mm acute subdural haemorrhage in the falx cerebri. Large left-sided subgaleal haematoma without underlying skull fracture. Small left pleural effusion with tracheal secretions. Soft tissue injury in the right arm, possibly secondary to attempted cannulation. 11mm solid nodule at the right lung base - thought more likely to represent a discrete nodule than focal atelectasis; 3-month follow-up CT recommended if clinically indicated. No bony fracture identified. No visceral injury.

Impression:
Traumatic acute subdural haematoma.
AF with rapid ventricular response. 
Elevated WBC with neutrophilia secondary to trauma. 
Incidental right lung base nodule requiring follow-up. 
Elevated TSH suggesting poor compliance with thyroxine replacement

Management Plan:
1. Neurosurgical referral for observation and advice regarding traumatic subdural haematoma - for local observation
2. Reversal of DOAC with PCC - performed by ED team.
3. Stop rivaroxaban - consider switch to apixaban on discharge.
4. If heart rate does not settle following adequate analgesia, consider rate control for fast AF.
5. Admit for 24-48 hours of observation to ensure no deterioration.
6. Analgesia
7. Neuro obs
8. Three-month follow-up CT chest for incidental 11mm right lung base nodule - NOT REQUESTED
9. Escalation: For active full ward-based care. Not for CPR. DNACPR form completed August 2025.

Summary

Investigations

Plans