Physician's Assistant

Refined clerking Sun 10 August 2025 03:34

Last Modified: 239 days ago

MRN:

Content:

Medical ST4 Miller Clerking

Presenting Complaint:
Chest pain and shortness of breath for 12 months

History of Presenting Complaint:
Mr Hawton is an 89-year-old gentleman who presented via NHS 111 with worsening chest pain and shortness of breath. He reports a 12-month history of progressively worsening exertional dyspnoea, with exercise tolerance now reduced to approximately 50 yards on the flat before requiring rest. Previously he was very active, walking long distances across Dartmoor. The shortness of breath is accompanied by chest discomfort, described as a dull ache rather than sharp pain, located centrally and radiating to the left side. Symptoms are exacerbated by exertion and walking uphill.

On the day of admission, he experienced a more severe episode around 8pm whilst sitting at home. The chest discomfort was associated with a sensation of trapped air in his chest that he was unable to expel, resembling indigestion. He had lost his appetite earlier that evening, unable to finish his meal at 5pm. The discomfort persisted and prevented him from sleeping, prompting him to call NHS 111. At present, his chest pain has resolved.

Past Medical History:
• Acute myocardial infarction (September 2007) - treated with PCI to LAD with stent insertion
• Single vessel coronary artery disease (LAD)
• Type II diabetes mellitus (2019)
• Seronegative rheumatoid arthritis (2007)
• Previous stroke (cerebral artery occlusion)
• Duodenal ulcer (2003)
• Depression (1977, 1992)
• Previous atrial fibrillation (resolved 2011)

Drug History:
• Bisoprolol 2.5mg PO OD
• Metformin 500mg PO BD
• Omeprazole 20mg PO OD
• Simvastatin 40mg PO OD

Allergy History:
• Ramipril - synovitis and tenosynovitis, shoulder and wrist pain
• Trimethoprim - avoid concurrent use with methotrexate

Social History:
Lives alone independently in Laira, Plymouth. Manages all activities of daily living without assistance. Has close family support with brother living in the same road and sister nearby with large family. Retired sewing machine mechanic, previously worked for Singer and later as delivery driver for Crown Paints. Never smoker. Enjoys photography as a hobby, previously very active walking on Dartmoor. No alcohol history mentioned.

On Examination:
General Appearance: Alert, comfortable at rest, appears tired
Observations: Not documented
• Cardiovascular: Heart sounds normal, no murmurs heard, no ankle oedema observed
• Respiratory: Chest clear on auscultation
• Other: Lower limbs - no swelling, rashes or oedema noted

Investigations:
Bloods planned: FBC, U&E, troponin, glucose
ECG planned: To assess for acute changes
Chest X-ray planned: To exclude other causes of chest pain

Impression:
Unstable angina secondary to progression of known coronary artery disease
Differential Diagnoses: Acute coronary syndrome, gastro-oesophageal reflux disease, musculoskeletal chest pain
Type II diabetes mellitus - stable
Seronegative rheumatoid arthritis - stable

Management Plan:
1. High-dose aspirin commenced for acute coronary syndrome
2. Serial troponins and ECGs to rule out myocardial infarction
3. Chest X-ray to exclude other causes of chest pain
4. Cardiology review and consideration of repeat angiography given previous single vessel disease with untreated vessel
5. Continue current cardiac medications
6. Bed rest overnight with cardiac monitoring
7. Admit to Cardiology/Medical Ward
8. Escalation plan to be discussed - suitability for CPR, ITU and NIV to be determined

Field Clipboard (for EPR paste)

Builds copy buttons from the headings currently in the note, and also lets you copy the entire note.

Summary:

Investigations:

Refined clerking Sun 10 August 2025 03:34

Field Clipboard (for EPR paste)

Tasks

Feedback