Physician's Assistant

Refined clerking Mon 04 August 2025 06:03

Last Modified: 35 weeks ago

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Medical ST4 Miller Clerking

Presenting Complaint:
Hypertension

History of Presenting Complaint:
This 86-year-old lady presented generally unwell, lightheaded, weak, possible right-sided facial droop. This resolved at the time of assessment. She has been experiencing bilateral leg swelling up to her knees for several months, which has been progressively worsening.
The swelling is particularly noticeable and causes her legs to feel heavy when walking. The patient feels that her mobility has been affected by the heavy sensation in her legs.

She denies any chest pain or acute shortness of breath but acknowledges feeling more limited in her walking distance.

Recent admission with accelerated hypertension, managed with doxazocin. Recently stopped by GP after reports of morning nausea.

ACEi have led to leg swelling.

Past Medical History:
• Hypertension (February 2025)
• Heart failure with preserved ejection fraction
• Ischaemic heart disease (2003)
• Previous coronary angioplasty (2003)
• Chronic kidney disease stage 3 (2015)
• Age-related macular degeneration - both eyes
• Bilateral cataracts - surgically treated (2024)
• Left hip osteoarthritis (June 2023)
• Gastro-oesophageal reflux disease (June 2023)
• Vitamin B12 deficiency (2018)
• Anaemia (April 2020)
• Previous total abdominal hysterectomy (1975)
• Previous emergency appendicectomy (1979)

Drug History:
• Losartan 50mg PO OD
• Simvastatin 20mg PO ON
• Omeprazole 20mg PO OD
• Cyanocobalamin 50mcg PO BD
• Ferrous sulfate 200mg PO OD
• Glyceryl trinitrate 400mcg sublingual spray PRN
• Pregabalin 100mg PO ON
• Diclofenac diethylammonium 2.32% gel BD topically
• Epimax original cream PRN
• Medi Derma-S barrier cream BD topically

Social History:
Lives with partner of approximately one year. Uses walking stick but often walks without it indoors. Uses 3-wheeled walker with seat outdoors. Partner provides support with daily activities. Never smoked. Independent with most activities but limited by leg swelling and heaviness.

On Examination:
General Appearance: Alert, well-appearing elderly lady, comfortable at rest
Observations: Initial BP 234/82 mmHg, HR 76/min, RR 20/min, O2 sats 96% on air, Temp 36.9°C
Post-doxazosin: BP 147/67 mmHg, HR 64/min
• Cardiovascular: Bilateral basal crepitations
• Extremities: Significant bilateral leg oedema extending to hips
• Abdomen: Soft and non-tender
• Neurology: No limb weakness or facial droop.

Investigations:
• CT Head: No intra or extra-axial haemorrhage, no mass effect or acute infarct, diffuse cerebral atrophy consistent with age, chronic lacunar infarcts bilaterally in basal ganglia
• CRP: 6
• Sodium: 148
• Creatinine: 101
• ALP: 144 (previously elevated)
• Troponin: 4
• Full blood count: normal
• INR: normal
• TTE (24/02/2025): Normal LV size with preserved systolic function (EF 55-60%), mildly dilated RV with reasonable function, mild AS, trace AR
• 24h Holter (March 2025): Sinus rhythm with infrequent sinus tachycardia, first degree AV block throughout
• CXR:

Impression:
Transient neurological symptoms
secondary to hypertensive encephalopathy
secondary to accelerated hypertension
secondary to fluid overload
secondary to heart failure with preserved ejection fraction
Raised ALP secondary to above

Management Plan:
1. commence furosemide for diuresis
2. Aim for discharge home today with virtual ward follow-up to recheck UE, BP, weights and consider cessation of doxazosin once diuresis achieved
3. Consider escalation of furosemide dose if inadequate diuresis or switch to bumetanide
4. CXR [/]

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Summary:

Investigations:

Refined clerking Mon 04 August 2025 06:03

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