Physician's Assistant

Refined clerking Sat 27 September 2025 21:52

Last Modified: 190 days ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Decreased responsiveness

History of Presenting Complaint:
More unwell over 2 days, less oral intake, more drowsy

Acutely drowsy and less responsive with son this evening. Called ambulance. Hypoxic and hypotensive with crew.

Decision made to switch to palliative care by ED team soon after arrival.

Past Medical History:
• Metastatic small cell lung carcinoma - diagnosis January 2025, declined further active treatment March 2025
• Chronic obstructive pulmonary disease
• Rheumatoid arthritis
• Hip and knee OA
• Essential tremor
• Acquired hypothyroidism (1996)
• Peripheral vascular disease
• Osteopenia

Drug History:
• Morphine sulphate 10mg/5ml oral solution 2.5-5ml PO QDS PRN
• Paracetamol 1000mg PO PRN
• Celecoxib 100mg PO BD
• Lansoprazole 30mg PO OD
• Atorvastatin 40mg PO nocte
• Levothyroxine 100mcg PO OD
• Clonazepam 500mcg PO BD
• Sulfasalazine 500mg PO BD
• Primidone 50mg PO OD (morning) and 25mg PO OD (evening)
• TheiCal-D3 1000mg/880unit PO OD
• Escitalopram 20mg PO OD
• Trimbow inhaler 2 puffs BD via spacer
• Salamol inhaler 1-2 puffs QDS PRN

Allergy History:
NKDA

Social History:
Lives with son. Not coping well at home over last few months.

On Examination:
General Appearance: Comfortable lying in bed, responsive to pain only
Observations: HR 140, BP 135/74 (improved from 80/54), O2 sats 96% on high flow oxygen (previously 86% on air), feels hot to touch - febrile
• Cardiovascular: Bounding pulses, warm peripheries
• Respiratory: Bilateral Left > right lower zone coarse crepitations on auscultation
• Abdomen: Soft and non-tender
• Other: Staining on fingers, mild pitting peripheral oedema to knees bilaterally, dry tongue

Investigations:
• Blood cultures: Negative so far
• Sodium 155 (previously 141)
• Potassium 2.4 (previously 3.5)
• Creatinine 61 (previously 53)
• INR 7.7
• Haemoglobin 131
• Platelets 128
• Neutrophils 12.81
• ALT 111
• Albumin 33
• ALP 274
• Bilirubin 68
• Protein 48
• CRP 87
• Urea 10.6
• AST 126
• Venous blood gas: pH 7.49, lactate 5.1, glucose 5.9
• CT April 2025: Left superior mediastinal node reduced in volume, left upper disease significantly reduced, left lower lobe nodule stable, multiple small liver metastases more prominent than March but reduced compared to PET scan, subtle sclerotic changes at bone metastases sites suggesting treatment response

Impression:
Deterioration with likely left lower lobe pneumonia on background of metastatic small cell lung carcinoma
Profound electrolyte abnormalities, significant coagulopathy likely multifactorial with vitamin K deficiency and metastatic liver disease contributing

Management Plan:
1. Add on TSH to exclude thyrotoxic crisis/thyroid coma
2. Scale 2 oxygen saturations and oxygen therapy for comfort
3. Update next of kin - updated at bedside.
4. Just in case medications
5. TEP: WBC
6. Admission to hospital side room for ongoing palliative care
7. Any hospital side room

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Summary:

Investigations:

Refined clerking Sat 27 September 2025 21:52

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