Physician's Assistant

Clerking Sun 29 June 2025 16:03

Last Modified: 281 days ago

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Medical ST4 Miller Clerking

Presenting Complaint:
Haemoptysis and shortness of breath

History of Presenting Complaint:
2 day history of haemoptysis and progressive dyspnoea. Fresh red haemoptysis multiple times over the last 2 days. Associated with this, has noticed right leg swelling and tenderness to palpation. Known haemodialysis patient with end stage renal failure undergoes dialysis 3 times a week. Most recent dialysis session 2 days ago (Friday).

Oliguric today - only 1x small volume urine passed. Note letters showing 2.5 L passed in March.

Past Medical History:
• Burnt out tubular interstitial nephritis on renal biopsy (August 2020)
• Current haemodialysis - 2 failed fistulas on left arm, right sided fistula appears to be functioning
• Previous uraemic pruritus
• Hepatitis B core antibody positive
• Listed for renal transplantation
• Bilateral salpingo-oophorectomy and supracolic omentectomy for benign ovarian serous cyst adenofibroma (March 2023)

Medication History:
• Atorvastatin 20mg PO ON
• Renavit 1 tab PO OD
• Warfarin as per INR - 5mg twice per week and 4mg other days
• Alfacalcidol 250 nanograms PO 3 times a week
• Calcichew 2 tablets PO TDS
• Renogel 800mg PO TDS
• Innohep 40mg on dialysis days
• Venofer 100mg IV once per fortnight
• Amlodipine 10mg PO OD
• Pramipexole 88 micrograms TT PO ON
• Eprex 4000 units IV 3 times a week

Allergic History:
Flucloxacillin and vancomycin

Social History:
Lives at home
Independent
Non smoker or drinker

On Examination:
Comfortable at rest. Vital signs: BP 155/98, HR 87, RR 18, O2 saturation 97% on air, temperature 36.6°C. Heart sounds normal. Bibasal crepitations on lung auscultation. Midline laparotomy scar. No abdominal tenderness. Pitting oedema to the knees bilaterally. ECG: sinus rhythm at 86 beats per minute with slightly prolonged QT interval, no evidence of ST elevation or ECG signs of hyperkalaemia.

Investigations:
Creatinine 894 with urea 24.3 and potassium 7.1 (haemodialysis patient). 
ALP 169, ALT 68, bilirubin 1.3 elevated. 
Haemoglobin 113 - stable anaemia. 
DD raised.
INR awaited

Impression:
Concerning for pulmonary embolism. 
- But seems less likely given warfarin use - possibly subtherapeutic?
Evidence of fluid overload
Hyperkalaemia despite recent dialysis - possibly spurious
- no ECG changes

Plan:
1. Add on INR [x] - If high then may explain haemoptysis, if low will need LMWH treatment-dose
2. CT pulmonary angiogram [_]
3. Green cannula for scan [x]
4. Renal discussion - likely to need dialysis after the scan plus electrolyte abnormalities
- If > 5.5 on gas then not spurious and aim for mayflower dialysis this evening
- Rechecked and 6.0 on VBG
- Dialyse clexane free for 2 hours of dialysis this evening to make her safe
- Chase INR - called lab - no add on form received. Further sample sent
- Treat high K now then transfer to Mayflower for dialysis
- Back to bed on AMU following HD

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Clerking Sun 29 June 2025 16:03

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