Physician's Assistant

Refined clerking Sat 20 September 2025 20:55

Last Modified: 198 days ago

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Medical ST5 Miller Clerking

Presenting Complaint:
Exertional chest pain and palpitations

History of Presenting Complaint:
This 68-year-old lady presented with a 1-week history of exertional chest pain and palpitations. One week ago she attended hospital with left-sided chest pain associated with palpitations and was diagnosed with paroxysmal atrial fibrillation. She was commenced on a direct-acting oral anticoagulant and bisoprolol.

Two days ago she felt woozy in the morning with symptoms suggestive of low blood pressure, which commonly affects her. She visited the pharmacy who advised cessation or dose titration of bisoprolol based on symptoms. She then attended A&E who advised she could consider stopping bisoprolol.

Yesterday morning she did not take her bisoprolol dose. In the evening whilst walking her dog, she noticed slight left-sided chest pain on exertion. She was able to walk through the pain without stopping, and the pain resolved when she ceased walking.

Later at home whilst watching television, she developed left-sided chest pain radiating to the jaw with associated palpitations but no shortness of breath. An ambulance was called. The chest pain has now resolved but lasted for many hours overnight.

Past Medical History:
• Paroxysmal atrial fibrillation (recent diagnosis)

Drug History:
• Apixaban 5mg PO BD
• Bisoprolol 1.25mg PO OD

Recently Stopped Medications:
• Bisoprolol - stopped yesterday due to hypotensive symptoms

Allergy History:
Not documented

Social History:
Lives alone but with family close by
Retired IT worker
Independent and active
Non-smoker
No alcohol consumption

On Examination:
General Appearance: Well, not appearing in pain
Observations: HR 59, BP 119/64, Temp 36.8°C, RR 17, O2 sats 99%, EWS 0
• Cardiovascular: Normal heart sounds, no murmurs, good regular peripheral pulses, warm and well perfused, no peripheral oedema
• Respiratory: No crepitations on chest examination

Investigations:
• Chest X-ray: Clear lung fields
• ECG: Sinus rhythm at 80 bpm
• Troponin T: 6 (normal)
• LFTs: Normal
• CRP: 9
• INR: 1
• Amylase: 57
• Full blood count: Normal

Impression:
Stable angina - exertional chest pain concerning for coronary artery disease
Paroxysmal atrial fibrillation - evening chest pain episode likely attributable to AF
GRACE score 95 - 3% probability of death from admission to 6 months

Management Plan:
1. Add on cholesterol and glucose blood tests
2. Referral to rapid access chest pain clinic
3. Discharge home with safety netting advice to return if symptoms persist or worsen
4. Stop bisoprolol - no evidence of fast heart rate
5. Consider rhythm control strategy with flecainide if coronary artery disease excluded or if exertional symptoms persist on treadmill testing
6. Cardiology follow-up for assessment of potential coronary artery disease and alternative rhythm control strategy for atrial fibrillation

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Investigations:

Refined clerking Sat 20 September 2025 20:55

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