Physician's Assistant

Refined clerking Sun 10 August 2025 00:58

Last Modified: 239 days ago

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Medical ST4 Miller Clerking

Presenting Complaint:
Cough and chest pain for 2-3 days

History of Presenting Complaint:
Presents with new onset cough productive of white sputum over 2-3 days. Associated with left-sided chest pain and headache. Reports feeling generally unwell. This is a new symptom for the patient who does not normally suffer from respiratory complaints. No dyspnoea, fever or night sweats reported. No urinary or bowel symptoms.

Past Medical History:
• Frailty (2023)
• Left deep vein thrombosis (2019)
• Bilateral hip replacements - left (2016), right (2015)
• Left knee replacement (2011)
• Lower leg arthropathy (2011)
• Sciatica (1998)
• L5/S1 discectomy (1997)
• Right eyelid ptosis correction (1999)
• Ectropion correction (1997)
• Right foot metatarsophalangeal joint arthroplasty (1994)
• Hysterectomy and anterior colporrhaphy (1976)
• Previous superficial thrombophlebitis (1995)

Drug History:
• Viscotears 2mg/g liquid gel applied 3-4 times daily PRN
• Ibuprofen 5% gel applied up to TDS PRN
• Epimax original cream applied PRN for skin moisturising
• Famotidine 20mg PO OD
• Pregabalin 50mg PO BD
• Paracetamol 500mg PO QDS PRN
• Xailin Night eye ointment at bedtime
• Hylo Night eye ointment at bedtime

Allergy History:
• Diclofenac sodium - adverse reaction (severity unknown)

Social History:
Lives in nursing home in Torquay. Requires nursing care assistance with activities of daily living including washing and dressing. Uses electric wheelchair for mobility. Born in 1922 (age 98 years). Previously worked for water company until retirement in 1987. Ex-smoker - smoked from age 16 until 10 years ago. Originally from London, moved to Plymouth after marriage.

On Examination:
General Appearance: Alert, conversant 98-year-old lady, appears unwell
Observations: Not documented
• Cardiovascular: Heart sounds normal for age, no murmurs detected
• Respiratory: Clinical signs consistent with left-sided chest infection
• Abdomen: Soft, non-tender on palpation
• Neurological: Good hand grip bilaterally, able to move toes, hearing intact
• Other: Small skin lesion noted

Investigations:
Blood tests requested: FBC, U&Es, CRP, LFTs
Chest X-ray requested
Sputum sample for microscopy, culture and sensitivity
Urine sample and swab for infection screen

Impression:
Left-sided chest infection (community-acquired pneumonia)
Secondary issues: Advanced age, frailty, multiple comorbidities including previous thrombosis

Management Plan:
1. IV cannula insertion for antibiotic administration
2. Chest X-ray to confirm pneumonia and exclude complications
3. Blood tests including inflammatory markers and renal function
4. Sputum sample collection for culture and sensitivity
5. Commence IV antibiotics as per local antimicrobial guidelines
6. Supportive care with regular monitoring
7. Medical ward admission
8. Escalation plan to be discussed given age and frailty

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Investigations:

Refined clerking Sun 10 August 2025 00:58

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