Physician's Assistant

Refined clerking Fri 30 January 2026 23:13

Last Modified: 66 days ago

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Medical ST5 Miller Clerking
Fri 30 January 2026 23:13

Presenting Complaint:
Confusion

History of Presenting Complaint:
Mr Welch attended his GP practice for a routine diabetes appointment on 29th January 2026. During this appointment, he appeared confused, did not know his phone number, and was walking with his belt wrapped around his legs. He had stopped wearing his shoes properly, allowing his feet to slide in with the heels buckled under. He reported stopping his insulin in November 2025 without clear rationale, stating he "just decided to stop".

Collateral history from GP records revealed he had not been taking insulin for several months. Blood glucose on GP visit was 10.2 mmol/L. He demonstrated poor self-care with unkempt appearance and body odour. Cognitive assessment using 6-item cognitive impairment test scored 14/28. He thought the year was 2006.

He cooks for himself every other day, preparing mainly vegetables including cabbage, greens, sprouts and potatoes. Lives in shared accommodation. Denies feeling unwell and reports good mood generally.

On review of symptoms, no symptoms of note and no infective symptoms. No recent weight loss.

Past Medical History:
• Type 2 diabetes mellitus - latest HbA1c: 61 mmol/mol (January 2026), improved from previous 87 mmol/mol despite stopping insulin.
• Metabolic associated steatotic liver disease

Drug History:
• Metformin 500mg PO OD (not taking)
• NovoMix 30 FlexPen subcutaneous injections (self-discontinued November 2025)
• Vitamin C Supplements
• Selenium Supplements

Recently Stopped Medications:
• Atorvastatin - prescribed 2022, patient did not take
• NovoMix 30 FlexPen - stopped November 2025 without medical advice

Allergy History:
• Tetanus vaccine
• Wasp stings

Social History:
Lives in shared house in Torquay with communal kitchen facilities. Independent with cooking every day. Previously worked as dustman in Bristol
Mobility: Independent, walks well, cycles
Smoking: Current smoker, 3 cigarettes daily
Alcohol: 2 pints dark beer once weekly on Friday/Saturday
Functional Status: Independent with activities of daily living, cooks own meals, manages personal care

On Examination:
General Appearance: 78-year-old man, initially unkempt with poor body odour during GP visit, alert and conversational during hospital assessment
Jeans do appear a little dirty but otherwise reasonably kempt
• Cardiovascular: Regular pulse palpated, no peripheral oedema noted
• Respiratory: Chest clear on examination, no cough during assessment
• Neurological: AMTS score 8/10, oriented to person and place, disoriented to time (stated year as 2006), able to count backwards from 20 to 1 correctly
Dupuytren's contracture on the left, bowels opening regularly.

Investigations:
• Full Blood Count: Normal
• Bone profile including calcium: Normal
• Liver function tests: Normal
• CRP 20
• Urea and electrolytes Normal
• Magnesium Normal
• Venous blood gas Normal
• Chest X-ray Normal heart size and mediastinal outline, lungs clear
• CT Head No visible acute intracranial abnormality, background small vessel disease
• Urine dipstick with GP: No ketones, no evidence of infection

Impression:
Mild cognitive impairment with no clear acute reversible cause identified on current investigations
Differential Diagnoses: Early dementia, medication non-compliance effects, mild delirium (though CRP only mildly elevated)
Type 2 diabetes mellitus with recent insulin non-compliance but improving HbA1c

Management Plan:
1. No clear role for acute medical intervention
2. Add TSH to blood tests to exclude thyroid dysfunction as cause of cognitive impairment
3. Memory clinic referral as outpatient for further cognitive assessment and management
4. Taxi home

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Refined clerking Fri 30 January 2026 23:13

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