Physician's Assistant

Refined clerking Mon 22 September 2025 06:19

Last Modified: 192 days ago

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Medical ST5 Miller Clerking

Presenting Complaint:
Generally unwell and weak

History of Presenting Complaint:
Leon presents with general unwellness and weakness in the context of recent admission for obstructing renal stone. Recent urine culture from 16/09/2025 grew E.coli sensitive to amoxicillin, fosfomycin and nitrofurantoin. Current presentation represents deterioration in muscular dystrophy secondary to urinary tract infection with possible infected obstructed kidney. Patient has developed renal angle tenderness and systemic unwellness suggesting progression from simple UTI. Nutrition has become significantly compromised due to poor swallowing related to muscular dystrophy progression.

Past Medical History:
• Duchenne muscular dystrophy
• Scoliosis, non-ambulant since August 2016
• Osteopenia
• Sleep breathing disorder - on nocturnal non-invasive ventilation
• Coeliac disease (2007)
• Recent admission 15-16/09/2025: 4mm left PUJ obstructing stone with moderate hydronephrosis, hypotensive episode with LVEF 61% on echo (previously 42% in February 2025)

Drug History:
• Ferrous fumarate 140mg/ml oral solution 2 spoonfuls daily
• Beclometasone 100mcg 2 puffs OD-BD
• Spironolactone 12.5mg PO OD (held due to hypotension)
• Enalapril 2.5mg PO BD (held due to hypotension)
• Bisoprolol 0.5mg PO OD
• Salbutamol nebuliser 1 ampoule BD PRN
• Carbocysteine 750mg PO TDS
• Salbutamol 100mcg inhaler 1-2 puffs QDS PRN
• Unknown medication 150mg tablets 2 TDS (stock issue January 2021)

Recently Stopped Medications:
• Enalapril and spironolactone - held by mother due to hypotension on advice from Derriford cardiology

Allergy History:
Not documented

Social History:
Lives with mother who provides care
Non-ambulant since 2016
Requires assistance with activities of daily living
Significant functional impairment due to Duchenne muscular dystrophy

On Examination:
Alert but appears unwell
Observations: HR 100, BP 111/69, Temp 36.5°C, RR 17, O2 sats 100%
• General: Scoliotic, weak arms, hyperdynamic thrusting apex
• Cardiovascular: Regular peripheral pulses, normal heart sounds with systolic flow murmur heard throughout precordium
• Respiratory: Quiet lung bases bilaterally, no focal signs of chest infection
• Abdomen: Soft with left renal angle tenderness
• Other: No peripheral oedema, no rashes

Investigations:
• Sodium and potassium: Within normal range
• Lymphocyte count: 17 (baseline 3, was 12 during recent admission)
• Urea: 2.2 (baseline 0.5)
• Neutrophil count: 7.19
• Urine MC&S (16/09/2025): E.coli sensitive to amoxicillin, fosfomycin, nitrofurantoin
• CT KUB (previous admission): 4mm left PUJ obstructing stone with moderate hydronephrosis
• Echocardiogram (previous admission): LVEF 61%

Impression:
Deterioration in muscular dystrophy secondary to urinary tract infection
Obstructed renal system with concomitant infection - possibility of infected obstructed kidney
Secondary issues: Massively decreased nutrition due to poor swallow secondary to muscular dystrophy progression

Management Plan:
1. IV antibiotics - Co-amoxiclav given comorbidities and systemic unwellness
2. Urology review regarding potential infected obstructed kidney
3. Analgesia for renal angle tenderness
4. Continue overnight BiPAP as tolerated
5. Laxatives and enemas
6. SALT review for swallowing assessment
7. Dietetic review - consider short-term tube feeding
8. Input/output charting
9. Medical ward admission with cardiology input if required

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Summary:

Investigations:

Refined clerking Mon 22 September 2025 06:19

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