Physician's Assistant

Refined clerking Fri 09 January 2026 01:58

Last Modified: 87 days ago

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Medical ST5 Miller Clerking
09/01/25 01:00

Presenting Complaint:
Fall with long lie

History of Presenting Complaint:
This 68-year-old gentleman was found collapsed on the floor of his home after being there for approximately 36 hours.

He had experienced 6-7 falls over the preceding few days.

Paramedics noted the house was unkempt. At time of discovery, he was GCS 13, lying on his back next to his bed. He has had multiple falls over November, December and January according to the GP record.

He reports feeling well recently otherwise but describes low mood with feelings of loneliness. He has had significant unintentional weight loss of 6-7 stone over 15 months despite maintaining good appetite.

He was found to be in diabetic ketoacidosis with glucose of 23.8 on admission, acidotic with venous pH 7.29, and dehydrated.

He lives alone and usually manages independently with support workers helping twice weekly with shopping and separate cleaners attending twice weekly.

He has these carers mostly due to his inherited mitochondrial condition as opposed to his stroke.

Past Medical History:
• Phenotypic mitochondrial cytopathy with restrictive pulmonary function tests and impaired swallow
• NAFLD cirrhosis with portal hypertensive gastropathy
• Sleep disordered breathing on CPAP
• Previous asbestosis and pleural thickening
• Type 2 diabetes mellitus (2019) with microalbuminuria
• DDD permanent pacemaker (2017)
• Stroke (2005) - No residual disability he tells me
• Hypertension
• Anxiety
• Pancreatic exocrine insufficiency
• Barrett's oesophagus (2cm segment, uncomplicated)

Drug History:
• Dapagliflozin 10mg PO OD
• Atorvastatin 40mg PO OD
• Gliclazide 80mg PO OD
• Metformin 1g PO BD
• Aspirin 75mg PO OD
• Citalopram 40mg PO OD
• Lansoprazole 30mg PO OD
• Dipyridamole MR 200mg PO BD
• Trospium chloride (Regurin) 20mg PO BD
• Ramipril 5mg PO OD PRN

Allergy History:
NKDA

Social History:
Lives alone in a flat. Uses walking stick outdoors with exercise capacity limited to 5 minutes on flat ground. Has formal support workers twice weekly for shopping assistance  and separate cleaners twice weekly. Has some assistance with showering. Has friends nearby but no children. Previously worked as motor mechanic with asbestos exposure from brake pads. Ex-smoker (10 years, quit 2-3 years ago). Denies alcohol use. Independent with washing and dressing.

On Examination:
Observations: HR 126-130, BP 89/61, RR 20, O2 sats 96% on air
• Cardiovascular: Fast irregular pulses, heart sounds normal, bilateral lower limb oedema to knees
• Respiratory: Bilateral coarse crepitations to mid-zones
• Neurological: No clear focal deficit from previous stroke
• Skin: Left frontal soft tissue swelling, facial bruising left side, pressure injuries to buttocks and back, minor skin loss to foot
• Other: Cool peripheries, dry mucous membranes

Investigations:
• Venous blood gas: pH 7.29 improving to 7.41, base excess -10 improving to 2.2, lactate 3.4 (was 2.9), K+ 3.4 (was 3.1), PCO2 5.8
• FBC: Hb 151, WCC 24.3, neutrophils 20.37
• U&Es: Creatinine 101 (baseline 69 - AKI stage 1), urea 12.9 (was 4.6), electrolytes normal
• LFTs: Albumin 29, ALP 137, AST normal
• Other: CK 1020, CRP 148 (was 2), ferritin 1407, TSH normal, B12 and folate normal, INR 1.4 (was 1.2)
• Glucose: 23.8 on admission, now 8
• ECG: Sinus tachycardia, narrow complexes, rate 117 (? AF with fast ventricular response)
• CT Thorax/Abdomen/Pelvis: Left frontal soft tissue swelling, left-sided rib fractures, multiple new bilateral pulmonary opacities with ground glass attenuation concerning for infection, enlarged right paratracheal node, significant enlargement of left apical spiculated mass now showing cavitation, multiple non-displaced rib fractures, pancreatic atrophy and calcifications, faecal loading, liver normal
• Aspergillus serology: Negative

Impression:
Multifactorial ketoacidosis - Resolved with FRII
- Starvation ketosis following long lie
- Hyperglycaemic diabetic ketoacidosis excacerbated by dapagliflozin
Bilateral chest infections (likely aspiration), 
Acute kidney injury stage 1, 
Impending Rhabdomyolysis
Pressure injuries
Enlarging cavitating left apical lung lesion - malignancy (vs TB)

Management Plan:
1. Continue fixed rate insulin infusion until acidosis resolved, then convert to variable rate
2. Continue IV fluids for dehydration and AKI
3. Repeat ECG to clarify rhythm (? AF)
4. Suspend ramipril, trospium, and metformin
5. Tazocin for bilateral chest infections
6. Monitor urine output (catheter insertion attempted by surgical team but unsuccessful due to phimosis) - but passing urine
7. Pressure area care for skin injuries
8. Consider ITU review if develops fluid overload or requires vasopressor support
9. Sputum MC+S + AFBs if produces
10. Quantiferon testing to ascertain if TB is a possbility
11. Escalation status: Full escalation currently

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Summary:

Investigations:

Refined clerking Fri 09 January 2026 01:58

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