Physician's Assistant

Refined clerking Thu 18 September 2025 22:06

Last Modified: 200 days ago

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Medical ST4 Miller Clerking

Presenting Complaint:
Breathlessness for 3 days

History of Presenting Complaint:
Increasing shortness of breath over 3 days. Symptoms have been progressively worsening despite antibiotic treatment. Has underlying bronchiectasis and has been taking amoxicillin rescue pack for bronchiectasis flare.

Cough but at baseline and not more productive. Associated wheeze. Feeling dizzy and experiencing episodes of feeling hot and cold, no documented fevers. Denies chest pain but reports some chest ache.

HR 36 on home saturations monitor. 5 doses of atropine given by ambulance crew at 5-minute intervals with no effect.

Past Medical History:
• Bronchiectasis (2022)
• Previous stroke
• Chronic kidney disease stage 3 (2011)
• Sarcoidosis (2005)
• Interstitial lung disease (2005)
• Total hip replacement (2008)
• Osteoarthritis of hip
• Migraine with aura (2004)
• Tinnitus (2020)
• Previous cataract surgery (2003)
• Hyperlipidaemia (2006)

Drug History:
• Amoxicillin 500mg PO TDS (rescue pack for bronchiectasis flares)
• Doxycycline 100mg PO three times per week (UTI prophylaxis)
• Lansoprazole 15mg PO OD
• Simvastatin 40mg PO ON

Allergy History:
NKDA

Social History:
Lives at in a house with wife. Still working intermittently as a barber, usually customers come to him at home. Mobilises with a stick. Stairlift. Denies smoking. Occasional glass of wine.

On Examination:
General Appearance: Short of breath, alert but appears unwell
Observations: HR 36, BP 180 systolic, RR 22, O2 sats 96% on air
• Cardiovascular: Normal heart sounds, JVP not raised, no ankle oedema
• Respiratory: Coarse crepitations to mid zones bilaterally
• Abdomen: Mildly distended and tympanic, bowels last opened yesterday
• Neurological: GCS 15, neurologically intact
• Other: Moist mucous membranes

Investigations:
• ECG: Mobitz type 2 heart block (2:1 block)
• Bloods: CRP 7, Hb 118, Cr 141 (92), Urea 14.9, Mg 0.45, TnT 20, TSH normal,

Impression:
Symptomatic bradycardia secondary to Mobitz type 2 second degree heart block
AKI 1 with hypomagnasaemia

Management Plan:
1. Cardiac monitoring on coronary care unit
2. TEP form: for full escalation given reversible cause
3. Clear fluids now, nil by mouth from 2am
4. Aim PPM tomorrow
5. If hypotensive or chest pain, consider isoprenaline given atropine ineffective
6. Slow IVI without Mg replacement in light of AV blockade

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Investigations:

Refined clerking Thu 18 September 2025 22:06

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