Physician's Assistant

Refined clerking Mon 22 September 2025 04:59

Last Modified: 28 weeks ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Dyspnoea and productive cough

History of Presenting Complaint:
This 75-year-old gentleman was discharged on 19th September 2025 following presentation to A&E with syncope and breathlessness. He had been experiencing increasing breathlessness over several months with three pillow orthopnoea. Initial investigation revealed a large left-sided pleural effusion with associated dependent collapse and a small right-sided effusion on chest X-ray. His furosemide was increased to 80mg in the morning and 40mg evening, and he was discharged awaiting pleural clinic review.

On 18th September 2025, pleural fluid aspiration was performed with 1.5 litres drained. Pleural fluid analysis showed exudative effusion with negative Gram stain and culture, and no malignant cells on cytopathology. Since the drainage procedure, he has developed a productive cough with green, orange, and white sputum. He has become increasingly unwell at home, not eating or drinking well, appearing confused, becoming bed-bound, and sleeping more than usual, prompting paramedic attendance.

Past Medical History:
• Lumbar spinal stenosis - previous spinal decompression
• Degenerative cervical myelopathy
• Chronic lymphocytic leukaemia
• Atrial fibrillation
• Chronic kidney disease stage 3
• Essential hypertension
• Type 2 diabetes mellitus
• Left ventricular failure
• Gout
• Gastro-oesophageal reflux
• Osteoarthritis of knees (bilateral)
• Previous fracture of multiple ribs

Drug History:
• Bisoprolol 2.5mg PO OD
• Furosemide 40mg PO BD
• Spironolactone 25mg PO OD
• Warfarin (as per anticoagulant treatment book)
• Atorvastatin 20mg PO OD
• Omeprazole 10mg PO OD-BD PRN
• Paracetamol 500mg PO QDS PRN
• Codeine 30mg PO QDS PRN (maximum 8 in 24 hours)
• Allopurinol 100mg PO BD
• Salamol inhaler 100mcg PRN
• Acidex oral suspension 10-20ml PRN
• Zerobase 11% cream topical PRN

Allergy History:
NKDA

Social History:
Lives with wife in own home. Retired commercial printer who ran printing presses. Uses zimmer frame since recent hospital discharge, previously walked with stick. Manages stairs with difficulty. Getting out of house once weekly with assistance from eldest son who lives locally. Ex-smoker, drinks 3-4 cans of lager per week. Functional capacity significantly reduced over recent months due to spinal problems and breathlessness.

On Examination:
Generally unwell gentleman, alert but appears tired. Eyes show blepharitis with inflamed eyelids but clear conjunctivae.
• Cardiovascular: Heart sounds normal, no peripheral oedema
• Respiratory: Left base decreased breath sounds, right lower zone coarse crepitations
• Other: Peripheral chronic venous changes in legs

Investigations:
• Pleural fluid analysis (18/09/25): Exudative effusion, Gram stain negative, culture negative, cytopathology no malignant cells
• Creatinine: 123 (from 108)
• ALT: 52 (previously normal June 2025)
• ALP: 191 (chronically raised)
• Bilirubin: 26 (previously 8)
• CRP: 146 (from 74)
• Urea: 12
• AST: 59 (from 28)
• FBC: Neutrophilia, monocytosis, significant lymphocytosis consistent with CLL
• NT-proBNP: 2600
• Chest X-ray (current): Right basal consolidation and haziness, left pleural effusion significantly improved post-drainage but with persisting left basal collapse/effusion and small right basal effusion

Impression:
Right basal pneumonia (hospital-acquired)
Background of recent pleural effusion (exudative, cause unclear)
Chronic lymphocytic leukaemia
Left ventricular failure (stable)

Management Plan:
1. IV antibiotics for hospital-associated pneumonia
2. Hold furosemide temporarily as no current evidence of clinical fluid overload
3. Pleural team review of results to guide further investigation of exudative pleural effusion
4. Input/output monitoring
5. Sputum MC&S
6. Blood cultures
7. Oxygen therapy 1L (currently requiring)
8. Eye drops for blepharitis
9. Encourage sitting up and sputum expectoration
10. Respiratory ward admission
11. Escalation plan: Patient appropriate for full active treatment including CPR given reversible cause

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 Mon 22 September 2025 04:59

Field Clipboard (for EPR paste)

Tasks

Feedback