Admission Notes: Patient Abigail Vance

Patient Name: Abigail Vance. Age: 79. Hospital: Moorfield District Hospital, Leeds. Date: 14th October. Admitting Doctor: Dr Scott. Admitting Nurse: Kyle.

Presenting Complaint: The patient was brought in by her son after a fall at home this morning. She complains of a persistent dull ache in her lower back and a strange burning sensation when she tries to walk. She also reports feeling very dizzy whenever she stands up too quickly.

History of Presenting Illness: According to her son, Mrs Vance used to be very active and used to take up exercise classes every week, but she stopped doing everything six months ago after her husband passed away. She gave up smoking ten years ago and has no history of major kidney disease or severe arthritis.

Past Medical History & Medications: She has type 2 diabetes, managed with diet and a personal glucose meter at home. She also takes daily medication for mild hypertension. Her son notes that she is usually very independent, but recently she has become quite confused and disoriented in the evenings.

Examination Findings: On general appearance, the patient looks frail, tired and slightly dehydrated. Her vital signs show a blood pressure reading of 115 over 75, a pulse of 82 beats per minute, an oral temperature chart reading of 37.6 degrees, and oxygen saturation at 97 percent on room air. She is alert right now, though somewhat drowsy.

Assessment & Fluid Balance: The nursing staff checked her admission notes and fitted an allergy band showing a severe allergy to penicillin. Her fluid balance chart shows very low water intake over the past forty-eight hours. There are no obvious pressure sores, but she is marked as a high falls risk due to her recent dizziness and poor mobility.

Working Diagnosis: Our initial assessment suggests a urinary tract infection causing acute confusion in a frail elderly patient, complicated by mild dehydration and a recent mechanical fall at home. We need to monitor her closely over the next twenty-four hours.

Management Plan: Admit the patient to Ward 3A for intravenous fluids and broad-spectrum antibiotics. Order blood tests, a full urine analysis, and a chest X-ray. Request a physiotherapy assessment for mobility support before discharge is considered.

Night Nurse Addendum (Handwritten by Kyle at 03:00): Just checked the patient again. She isn't just confused—she kept pointing to her bedside drawer and asking for her 'blue book'. I opened it and found she has severe undiagnosed hearing loss in her left ear, which explains why she didn't answer any doctor's questions properly all day!

Read again and choose the right answer

Why was Mrs Vance brought into the hospital?

• She had a fall at home and a dull ache in her back.
• She had a severe heart attack in the garden.
• She wanted a routine check-up for her diabetes.

What medical condition does she have a history of?

• Kidney disease and severe arthritis.
• Type 2 diabetes and mild hypertension.
• Asthma and chronic lung problems.

What is the working diagnosis for Mrs Vance?

• A broken hip from the fall.
• A urinary tract infection causing confusion and dehydration.
• A bad reaction to her penicillin medication.

What crucial clue did Kyle the night nurse discover?

• The patient was secretly eating sweets.
• The patient had severe hearing loss in her left ear.
• The patient was trying to run away from the ward.

Sources: photo by MART PRODUCTION on Pexels