Physician's Assistant

Refined ultra rapid review Sat 31 January 2026 20:22

Last Modified: 65 days ago

MRN:

Content:

Medical ST5 Miller Review

Reason:
Consultant asked me to review this 51-year-old lady with diagnostic uncertainty regarding multiorgan dysfunction following surfing incident.

History:
PMHx: Stage 2 Hodgkin's lymphoma 1996 (aged 22) treated with mantle radiotherapy. Prophylactic bilateral mastectomy with breast implantation and latissimus dorsi flap. Left supraclavicular schwannoma 2013 (resected, benign peripheral nerve sheath tumour, possibly secondary to previous radiotherapy). Hypothyroidism post-radiotherapy. Takes levothyroxine and HRT. Two children, both caesarean deliveries.

Presenting complaint: Patient was surfing at Mount Sands on 29th for couple of hours in wetsuit. Felt fine in water but developed severe fatigue walking uphill afterwards. Had to stop multiple times, felt dizzy and lightheaded. Eventually unable to stand, sat on path until ambulance arrived. Reports shoulder aches during walk. Had been well prior to incident with usual gym attendance and normal activity levels. Drinks alcohol socially, takes vitamin supplements (NMN, B12, vitamin D).

Current issues: Evidence of myocardial ischaemia with troponin T 969 but normal echocardiogram. Deranged LFTs with hepatocellular picture - ALT 2,483, bilirubin 39 (from normal), AST 2,177, ALP normal. Developing AKI - creatinine 90 from 77. INR 1.6 without anticoagulation (from 1.1). Hypothermia and hypotension refractory to fluids. Lactate 4.2 on admission. Reports epigastric and left iliac fossa pain.

Examination:
Regular bradycardic pulse, no hand signs, chest clear, tongue dry, no focal neurology. Abdomen: mild epigastric tenderness on deep palpation, bowel sounds present, no peripheral oedema. Bedside USS: good volume liver, no chronic liver disease, portal vein normal, bile ducts normal with no lithiasis, poor pancreatic views due to bowel gas but no clear echogenic foci.

Impression:
Most likely multiorgan dysfunction secondary to hypothermia following prolonged surfing exposure. CT findings likely secondary to fluid resuscitation for hypotension. However, persistent junctional rhythm and renal function derangement raises possibility of multisystem disease.

Plan:
1. Extensive investigation panel to exclude alternative causes
2. Viral screening: Hepatitis A, B, D, E, CMV, EBV, VZV, parvovirus B19, HIV
3. Ceruloplasmin and transferrin saturation
4. Autoimmune liver profile, ANCA, immunoglobulins
5. Add CK to blood tests
6. 9am cortisol to exclude adrenal insufficiency
7. TSH and T4 (awaited)
8. Discuss with consultant for review tomorrow morning

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Summary:

Investigations:

Refined ultra rapid review Sat 31 January 2026 20:22

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