Physician's Assistant

Refined clerking Wed 06 August 2025 02:54

Last Modified: 243 days ago

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Medical ST4 Miller Clerking

Presenting Complaint:
Shortness of breath today

History of Presenting Complaint:
Patient has been receiving chemotherapy for lung adenocarcinoma since Christmas, currently on "maintenance" chemotherapy (last treatment 3 weeks ago). 
He developed a productive cough over the last few days but was otherwise feeling well. Today he mobilised around Looe on a scooter and felt fine. Upon returning home, after using the toilet, he had multiple episodes of productive coughing. When trying to stand, his legs felt weak and he has no memory of subsequent events. His daughter found him on the floor, responsive to pain but still feeling weak. He then developed sudden onset shortness of breath with no chest pain, prompting ED attendance. He denies chest pain. Patient reports feeling tired but improving on oxygen therapy.
Feels very different to recent PE. Has been compliant with DOAC.

Past Medical History:
• Adenocarcinoma of lung (April 2025) - currently on "maintenance" chemotherapy - likely palliative intent as pt states "not curative"
• Pulmonary embolism (June 2025)
• Paroxysmal atrial fibrillation (May 2025)
• Type 2 diabetes mellitus (2001) - on insulin since 2011
• Essential hypertension
• Primary open-angle glaucoma
• Bilateral cataracts
• Microalbuminuria
• Bilateral vasectomy

Drug History:
• NovoMix 30 FlexPen - 44 units SC mane, 22 units SC evening
• Apixaban 5mg PO BD
• Bisoprolol 1.25mg PO OD
• Metformin 500mg PO BD
• Irbesartan 150mg PO mane
• Simvastatin 40mg PO nocte
• Cyanocobalamin 50mcg PO BD
• Brinzolamide 10mg/ml eye drops BD
• Timolol 0.5% eye drops BD
• Monopost 50mcg/ml eye drops OD at night (left eye)
• Hylo-Forte 0.2% eye drops QDS both eyes

Allergy History:
• Trimethoprim - unclear
• Ramipril - dry cough

Social History:
Mobilises around house and to shops with family. Can walk 40-50 metres without issue but struggles with hills. Lives with wife, on holiday together in Plymouth. Ex-smoker - smoked from age 14 to 1998 (approximately 35 pack years). Previously worked as a mechanic. No current pets/birds.

On Examination:
Alert
Observations: HR 67/min, BP 127/64 mmHg, Temp 36.4°C, RR 20/min, O2 sats 98% on Venturi 60%
• Cardiovascular: Normal heart sounds, good pulses, bilateral lower limb oedema to knees
• Respiratory: Decreased breath sounds bilateral bases, crepitations right coarser than left to mid-zone
• Other: Alert and responsive

Investigations:
• CXR: Effusion/collapse to right mid-zone, bilateral hazy opacification
• CRP 51
• Neutrophilia
• Hb 106
• Cr 91
• XR Chest 06 Feb 2025 (From GP Record): There is diffuse consolidation in the right lung. There is now collapse of the right lower lobe with a small right pleural effusion. Appearances have deteriorated from the previous x-rays. The left lung remains clear.

Impression:
Community acquired pneumonia - CURB65 3
Differential Diagnoses: 
- Progression of underlying lung adenocarcinoma
- Atypical infection (given immunocompromise from chemotherapy)

Management Plan:
1. Continue oxygen therapy - wean as able
2. Antibiotics
3. Request atypical infection screen
4. Continue current medications including anticoagulation for recent PE
5. Respiratory bed
6. Escalation plan as previously discussed - not for ITU/CPR
7. Clarify chemotherapy situation with Nottingham Hospital.

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Investigations:

Refined clerking Wed 06 August 2025 02:54

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