Physician's Assistant

Refined clerking Mon 20 October 2025 16:52

Last Modified: 24 weeks ago

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Medical ST5 Miller Clerking

Presenting Complaint:
Fall and generally unwell

History of Presenting Complaint:
This 82-year-old gentleman was recently admitted to Torbay under acute medicine on 17/09/2025 with pneumonia and constipation, complicated by AKI. Initial treatment resolved pneumonia and constipation but AKI failed to respond to prerenal management. Renal ultrasound demonstrated obstructing left ureteric calculus and multiple enlarged lymph nodes. He was transferred to Exeter for left nephrostomy on 28/09/2025, returning to Torbay on 04/10/25 under care of the Urology team.

Uretroscopy 08/10/25 for potential lithotripsy and stenting, however stone could not be visualised in ureter. Referral for external shock wave lithotripsy.

Perioperatively developed atrial fibrillation and was commenced on apixaban with plan for outpatient cardiology review.

Finding of multiple lymph nodes above and below diaphragm on recent CT TAP were discussed at haematology MDT on 15/10/2025 who felt these were not clinically significant.

Discharged on 14/10/2025 with nephrostomy in situ awaiting external shock wave lithotripsy. Three days following discharge, he had a fall at home stating he simply 'lost balance'. Developed right hip pain but remained weight-bearing. Reports pain at sacral pressure sore site.

Onset of central upper chest pain from 23:00 yesterday, described as tight sensation with gradual onset whilst in bed. Initially associated with shortness of breath which has resolved, but chest pain persists. Vomiting overnight. Denies fever. Mild abdominal pain but no diarrhoea. Reports normal nephrostomy output and passing urine normally. Right hip pain with ability to weight bear and dull ache around left hip.

Presented today with hyperkalemia on blood tests and feeling generally unwell.

Past Medical History:
• JAK2 positive polycythaemia rubra vera (2009)
• Left common femoral DVT (2009) - on warfarin until 2020
• Inferolateral MI (2009)
• Inferior STEMI (2020)
• Progression to myelofibrosis (2023)
• IgG lambda monoclonal gammopathy of unknown significance (MGUS) (2023)
• Jehovah's Witness

Drug History:
• Apixaban 5mg PO BD
• Ramipril 2.5mg PO OD (held)
• Lokelma (continued)

Allergy History:
NKDA

Social History:
Lives with wife, usually independent

On Examination:
General Appearance: Alert but unwell
Observations: HR 42 (improved following calcium gluconate), initially absent P waves now improved
• Cardiovascular: Heart sounds I and II with pansystolic murmur in mitral area, JVP at 2 fingers
• Respiratory: Clear lung fields bilaterally with moist basal crepitations
• Abdomen: Soft, non-tender, left nephrostomy in situ draining clear urine
• Other: Moist mucous membranes
Input 1644ml, output 355ml urine + 217ml nephrostomy)

Investigations:
• Creatinine 227 (baseline 96)
• Potassium 8.1, improved to 6.6 with shifting therapy
• Urea 19.9 (from 7.2)
• Troponin T 60
• Hb 110, Platelets 561, Neutrophils 12.68
• CRP 19 (previously 25)
• ALT 150 (from 18), ALP 225 (from 140)
• AST 146 (from 24), Total protein 84 (from 68)
• CT Urinary Tract (10/12/2025): Left nephrostomy in situ, pigtail mostly in renal cortex, 3 small non-obstructive calculi in left lower renal pole, no ureteric or bladder calculi
• CXR: No confluent consolidation or lobar collapse
• CT TAP (September 2025): Enlarged mediastinal hilar nodes, 7mm subpleural nodule RLL, obstructing left ureteral calculus, splenomegaly with splenic infarction, mediastinal hilar lymphadenopathy

Impression:
Hyperkalemia with ECG changes of unclear cause
- Pattern suggests possible obstructed nephropathy however nephrostomy appears functioning
Chest pain and raised TnT
Sluggish UO - possibility of pre-renal cause

Management Plan:
1. Bloods now for potassium recheck. Continue hyperkalemia treatment and monitor potassium levels 4hrly (3 rounds of shifting therapy given so far)
2. Send nephrostomy output and urine for urinary electrolytes (separately)
3. Hold ramipril
4. Continue Lokelma
5. Strict input/output monitoring
6. Pharmacological VTE prophylaxis
7. Consider renal input if potassium remains persistently high despite shifting therapy
8. IV fluids
9. Acute medical bed

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Investigations:

Refined clerking Mon 20 October 2025 16:52

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