Physician's Assistant

Refined clerking Thu 06 November 2025 10:54

Last Modified: 151 days ago

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Medical ST5 Miller Clerking

Presenting Complaint:
Shortness of breath

History of Presenting Complaint:
On holiday in Portugal last month where he presented with SOB and leg swelling. Diagnosed with AF and started on apixaban at that time. Taking for 4 weeks now with no missed doses.

Fevers with rigors 2 days ago with shortness of breath and non-productive cough. Temperature 38.5°C overnight.

Found to have a slow heart rate on monitor at circa 25. Initially had chest pain but this has resolved. Improved to 48 bpm following 2x atropine administration.

Exercise tolerance limited by intermittent claudication to 20 metres, with cramping leg pain requiring rest. Also experiences shortness of breath on exertion but claudication symptoms predominate. No chest pain on exertion.

Past Medical History:
• Atrial fibrillation (October 2025)
• Emphysema/COPD (2017)
• Essential hypertension (2002)
• Peripheral vascular disease (2015)
• Cervical spinal stenosis - revision decompression (May 2021)
• Stroke (2014)
• Mixed anxiety and depressive disorder (2014)
• Osteoarthritis (2015)

Drug History:
• Apixaban 5mg PO BD
• Nustendi 180mg/10mg PO OD
• Pregabalin 200mg PO BD
• Citalopram 20mg PO OD
• Ultibro Breezhaler 85microgram/43microgram inhaled OD
• Lisinopril 20mg PO OD
• Tamsulosin 400microgram PO OD
• Allopurinol 100mg PO OD
• Amlodipine 10mg PO OD
• Lansoprazole 15mg PO OD

Allergy History:
NKDA

Social History:
Lives with wife. Independent including mobility.
Mobility limited by intermittent claudication to 20 metres.
Ex-smoker - stopped 1984, previously 40 cigarettes per day for 16 years.
Alcohol - drinks once per week

On Examination:
General Appearance: Alert
Observations: HR 37, BP 111/81, O2 sats 97% on air, Temp 38.5°C overnight
• Cardiovascular: Normal heart sounds, pitting oedema to knees bilaterally
• Respiratory: Bibasal fine inspiratory crepitations
• Abdomen: Obese but soft and non-tender

Investigations:
• ECG: Initial atrial fibrillation rate 60, subsequent ECG rate 35, post-atropine rate 43
• Chest X-ray: Bilateral hazy lower zone opacification, fluid in fissures, upper lobe diversion
• Blood cultures: Negative so far
• COVID-19: Awaited
• INR: 1.3 (on apixaban)
• FBC: Lymphopenia, monocytopenia, eosinopenia, normal white cell count
• Creatinine: 140 (baseline 82-101) - AKI
• LFTs: Normal
• CRP: 29
• Urea: 9.1

Impression:
Lower respiratory tract infection - CURB65 of 3
Acute kidney injury 1
Atrial fibrillation with slow ventricular rate - requiring atropine

Management Plan:
1. Cardiac monitoring
2. IV antibiotics for chest infection - Co-trim as per guidelines
3. Slow IV fluids for AKI
4. IO monitoring
5. Sputum and urine MC&S
6. If repeated bradycardia with adverse features - isoprenaline infusion and discussion with cardiology for CCU
7. AMU
8. Escalation discussed - patient consents to full escalation including CPR and ITU care - currently reversible pathology with potential for rapid and reversible deterioration

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Refined clerking Thu 06 November 2025 10:54

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