Physician's Assistant

Clerking Fri 01 August 2025 23:00

Last Modified: 248 days ago

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Content:

Medical ST4 Miller Clerking

Presenting Complaint:
Hypertensive crisis during elective surgery

History of Presenting Complaint:
Patient admitted for elective total abdominal hysterectomy and bilateral salpingo-oophorectomy. In anaesthetic room, blood pressure 230/80 mmHg both non-invasively and arterially. Surgery postponed due to severe hypertension. Patient reports recent ankle swelling over past few weeks. Has noticed pulsatile tinnitus. Denies headaches or visual changes, chest pain or shortness of breath. Significant recent life stressors including house move scheduled for next week.

Past Medical History:
• Hypertension
• VSD repair 1984
• Tissue mitral valve replacement November 2024
• Asthma - uses inhalers
• Gallstones

Medication History:
• Candesartan 4mg PO OM
• Spironolactone 25mg PO OM
• Salbutamol 100mcg inhaler PRN
• Dapagliflozin 10mg PO OM
• Atorvastatin 20mg PO ON
• Bisoprolol 1.25mg PO OM
• Fostair Nexthaler 100mcg inhaled OD

Allergic History:
Allergy to protamine (caused swollen tongue and chest rash during previous procedure)

Social History:
Works desk job in construction company doing payroll. Lives with husband. Has home blood pressure monitor. Currently experiencing stress due to house move next week.

On Examination:
Observations: BP 175-184/66-74 in theatre, currently 180-200/60-70, Sats 90-96% on air, RR 18. Afebrile.
Bilateral ankle swelling to knees
Chronic venous changes in lower limbs
Chest examination performed - no signs of pulmonary oedema
Heart sounds - soft systolic murmur
Abdo - SNT

Investigations:
Blood tests: Creatinine 60 (normal), cholesterol and triglycerides normal, FBC normal, glucose normal, GGT mildly raised at 40, TSH normal
TTE Jan 25: Stable MVR in situ. LV normal EF > 55%.

Impression:
 Multifactorial hypertensive crisis secondary to:
1. Inadequately controlled essential hypertension
2. Recent life stressors
3. Clinical overload

Plan:
1. ECG [_]
2. Chest X-ray [/]
3. Start additional 4mg Candesartan tonight [/]
4. Increase Candesartan to 8mg OD with GP follow-up in 1 week [/]
5. Patient to maintain BP diary at home and discuss with GP
6. Restart furosemide 20mg OD [/]
7. Rebook surgery once BP controlled
8. Aim home mane

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Summary:

Investigations:

Clerking Fri 01 August 2025 23:00

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