Physician's Assistant

Refined clerking Fri 19 September 2025 06:22

Last Modified: 199 days ago

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Medical ST5 Miller Clerking

Presenting Complaint:
Shortness of breath for 3 days

History of Presenting Complaint:
3-4 days ago, visit from her grandchildren who had minor upper respiratory tract symptoms. Started to feel unwell 3 days ago with progressive SOB and temperature spike to 38.0°C. Felt particularly unwell today and presented.

She has not produced any sputum when coughing and has no significant dyspnoea. She has not required oxygen therapy and has been afebrile since admission.

Past Medical History:
• Left-sided Grade 3 invasive ductal carcinoma (22mm) - triple negative breast cancer
• Currently receiving neoadjuvant chemotherapy: 4 cycles weekly paclitaxel and carboplatin completed, continuing 3-weekly pembrolizumab and epirubicin/cyclophosphamide (EC)
• Depression

Drug History:
• Citalopram 10mg PO OD
• pembrolizumab and epirubicin/cyclophosphamide (EC) (3-weekly cycle - last dose Tuesday)

Allergy History:
• NKDA

Social History:
Lives alone, independently
Occupation: Works in eye surgery department in this hospital
Smoking: Never smoker
Alcohol: Non-drinker

On Examination:
General Appearance: Alert, not distressed
Observations: RR 17, 95% on air. HR 102, BP 105/62, T 37.9
• Cardiovascular: Heart sounds normal, no peripheral oedema. Tachycardic regular pulses
• Respiratory: Decreased breath sounds in left lower zone with crepitations in left mid zone
• Abdomen: Soft and non-tender
• Other: No leg rashes, moist mucous membranes

Investigations:
• Neutrophils 0.93 (previously 2.01)
• Lymphocytes 0.46 (previously 1.08)
• Eosinophils 0.01
• Lymphocytes 0.21 (previously 1.63)
• Creatinine 55 (baseline)
• Potassium 3.2 (previously 3.78 in July)
• INR 1.1
• Venous blood gas 1.3
• Chest X-ray: Hazy left lower zone opacification

Impression:
Left-sided community acquired pneumonia in neutropenic patient secondary to chemotherapy and immunotherapy
MASCC score 21

Management Plan:
1. Treat as neutropenic sepsis with IV antibiotics
2. G-CSF - stop once Neuts > 1.0 twice
3. IV fluids
4. Oncology ward side room
5. Daily neutrophil counts

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Investigations:

Refined clerking Fri 19 September 2025 06:22

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