Physician's Assistant

Refined clerking Sat 27 September 2025 04:20

Last Modified: 191 days ago

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Medical ST5 Miller Clerking

Presenting Complaint:
Acute confusion and fever

History of Presenting Complaint:
Developed urinary incontinence and increased confusion from baseline (dementia).

Fell twice, lowering himself to the floor.  No injury. Febrile (39°C) with ambulance crew. Much more confused and agitated than normal baseline. Denies pain. No other infective symptoms.

Following IV antibiotics and 500ml IVI, patient developed flash pulmonary oedema with oxygen saturations dropping to 50% on 15L non-rebreather mask. Required CPAP and cardioversion attempt (unsuccessful - remains in AF). Magnesium 4g total, Digoxin 500mg IV, Amiodarone 150mg

Past Medical History:
• Dementia/cognitive impairment
• Atrial fibrillation - on anticoagulation
• Transient loss of consciousness - investigated by cardiology with normal tilt table test
• Implantable loop recorder showing bradycardia (HR 35) and 4-5 second pauses (asymptomatic)
• Heart failure - EF 45% with severe tricuspid regurgitation
• Hypertension
• Knee osteoarthritis
• Hip osteoarthritis
• Prediabetes
• Small vessel cerebrovascular disease

Drug History:
• Sertraline 100mg PO OM
• Amlodipine 5mg PO OD
• Atorvastatin 20mg PO Nocte
• Digoxin 62.5mcg PO OD
• Omeprazole 10mg PO OD
• Rivaroxaban 20mg PO OD
• Carvedilol 6.25mg PO BD
• Ibuprofen 5% gel PRN TDS

Allergy History:
NKDA according to GP records (note adverse reaction to beta-blockers mentioned but currently on carvedilol)

Social History:
Lives with wife who struggles with his care. No formal package of care currently in place.

On Examination:
General Appearance: Unwell, confused, agitated
Observations: BP 120/68, RR 16, O2 sats 98% (on 10L with 50% FiO2), HR 77
• Cardiovascular: In atrial fibrillation
• Respiratory: Crepitations throughout, pulmonary oedema on lung ultrasound
• Abdomen: Soft, non-tender
• Other: No peripheral oedema, no rashes

Investigations:
• CRP: 48 (from 7)
• Creatinine: 109 (baseline 101)
• INR: 1.9
• Bilirubin: 68 (from 42, chronically raised)
• Urea: 7.9 (from 6.7)
• Platelets: 124 (from 169)
• VBG on admission: pH 7.42, worsening to 7.11 at 09:00 with lactate 5.2, then improving to pH 7.3 with lactate 2.1
• ABG: pH 7.35-7.37, PCO2 6.26 (latest: pH 7.3, PCO2 6.8, lactate 2)
• CXR: Awaited
• Urine dip: Performed
• COVID swab: Performed

Impression:
Urinary tract infection with sepsis
Flash pulmonary oedema secondary to AF with RVR and IVI plus underlying heart failure (EF 45%, severe TR) - Improving
Delirium on dementia

Management Plan:
1. IV antibiotics (Tazocin/Gentamicin) continued
2. Aim to wean to Airvo when stable
3. Rate control held until infection treated
4. Hold further IV fluids
5. Review rate am and consider further digoxin loading
6. NIV ceiling of care - not for ICU or CPR

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Refined clerking Sat 27 September 2025 04:20

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