16:40 · Arrival
The story of the fall
She was standing at the checkout, felt nothing at all, and was on the floor. Witnesses say she was out for ten seconds, pale, no shaking, and back to herself immediately. A grazed elbow, nothing more. She is embarrassed and wants to leave.
Vitals
HR52BP142/78RR16SpO297%T36.6
History
- Any warning at all: nausea, warmth, tunnel vision?
- None. 'The lights just went out.'
- Anything similar before?
- Two 'dizzy spells' this month, put down to standing up quickly.
- Medications?
- Ramipril, metformin, and bisoprolol started three weeks ago for 'ectopics'.
- On standing?
- No drop: 138/76 after three minutes upright.
Examination
- Cardiac: Slow regular pulse; no murmur; JVP normal
- Neurological: Intact; no injury beyond the elbow
Build the problem list
One problem per line, most urgent first. Abbreviations are fine.