Your Senior House Officer (SHO) has accepted a patient from A&E and has asked you to clerk while she reviews a ward patient



"Hi, I'm Alex, one of the A&E SHOs. Your SHO asked me to handover Mrs Howells to you."



"She's on trolley 7 in majors. She's been brought in by her daughter following a witnessed fall. She has a head injury with a scalp laceration we've treated. The daughter says she's more confused but only recently she was formally diagnosed with mild cognitive impariment."



"She's stable now and I have someone in resus I need to see, can I leave her to you? Thanks."





You go ahead and introduce yourself before taking a history



Presenting Complaint (PC): Witnessed fall with head injury (HI)


History of Presenting Complaint(HPC): She was out having lunch with her daughter. She says she doesn't recall feeling unwell. She remembers falling and hitting her head, no loss of consciousness (LOC). She then proceeds to tell you about her tabby cat, complains about her head hurting and the lump she's got before continuing to tell you about her little grey kitten instead.



Asking the daughter, she says Mrs Howells was her usual self at lunch but then complained about feeling a little light headed and as she turned back around from getting a chair, she saw the last seconds of her mum falling backwards and hitting her head. She denies any vomiting and hasn't notice anything other than the increased confusion. She was able to weight bear and was walked, aided, back to the car and brought to A&E.



Past Medical History (PMH):

  • Recently diagnosed with mild cognitive impairment
  • Diabetes mellitus Type 2 (T2DM)
  • Hypertension (HTN)
  • Hypothyroidism

Family History (FHx): Nil relevant



Social History (SHx): She normally mobilises independently with a stick. She lives alone but her daughter is 4 doors down her street. Non smoker, never smoked. EtOH (Alcohol/ethanol) only socially. Only minimal exercise weekly, but tries her best and walks as much as she can in the house.



Systems review: No fatigue or weight loss. No Cardiovascular (CV), Resp, GI (Gastrointestinal) or MSK (Musculoskeletal) symptoms.


Neuro - Recent diagnosis of mild cognitive impairment.

GU (Genitourinary) - She complains of some urinary frequency and dysuria.



On examination:


From the end of the bed, she looks well. Save the bandage on the back of her head, nothing catches your eye. She is happily chatting with her daughter and smiles at you.



A quick chest and abdo examination is unremarkable.


Normal tone in all four limbs

Upper Limb: L 5/5, R 5/5

Lower Limb: L5/5, R 5/5

There is a small amount of non-specific upper limb numbness

Co-ordination normal throughout



The cranial nerves exam is unremarkable



Your SHO calls you back to the ward as Mrs Howells is transferred to Medical Assessment Unit (MAU)



"So, what do you think?"


HR 77 bpm

(Sinus on ECG)

BP 115/75

RR 12

O2 98% RA(room air)

Temp 36.5oC



"Hello doctor"


This is Mrs Howells


Her daughter is sat beside her bedside



You are the medical F1 on take in a busy DGH







Medications (Rx):

NKDA (No Known Drug Allergies)

  • Metformin 1g Four times a day (QDS)
  • Amlodipine 5mg Once per morning (OM)
  • Bendroflumethiazide 2.5mg OM
  • Doxazocin 2mg OM
  • Levothyroxine 75mcg OM


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"Hello doctor"


This is Mrs Howells


Her daughter is with her