Physician's Assistant

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Medical ST5 Miller Clerking

Date/Time: 26/02/2025, 19:02

Presenting Complaint:
Acute breathlessness

History of Presenting Complaint:
Colin Penn is an 88-year-old gentleman who presented to Torbay Hospital A&E with acute breathlessness. Collateral history obtained from paramedics and his son (Robert Penn, contacted by telephone) indicates he has been feeling generally unwell for the approximately 10 days prior to presentation. He lives alone in an assisted living apartment complex in the Torquay area. His son lives in North Devon and has had only intermittent telephone contact; he was not aware of any acute deterioration prior to this admission. No further collateral history was available from individuals who may have seen him more recently.

On presentation, he was hypoxic with saturations of 85% on air, requiring escalation to high-flow nasal oxygen (Optiflow) at FiO2 90% and 50L/min flow to achieve saturations of 90-92%. He was noted to be drowsy with a dry tongue. Bilateral pitting oedema to the hips was present. Respiratory examination demonstrated expiratory polyphonic wheeze throughout with coarse crepitations to the mid zones bilaterally, consistent with pulmonary oedema. ECG demonstrated atrial fibrillation with PVCs and biphasic T-waves in V5 and V6, without clear evidence of acute ischaemia on repeat tracing. Biochemistry revealed a metabolic acidosis with an elevated lactate, hyponatraemia, hypocalcaemia, elevated ALP and bilirubin above his established Gilbert's syndrome baseline, and a rise in neutrophils and white cell count. Troponin T was 24, though the sample was haemolysed and is difficult to interpret in isolation. The clinical picture and ECG changes are felt to be consistent with a missed myocardial infarction approximately 10 days ago, with subsequent acute decompensated heart failure. Further furosemide and salbutamol have been prescribed.

Past Medical History:
• Atrial fibrillation
• Hypertension
• Chronic kidney disease, stage 3
• Gout
• Gilbert's syndrome
• Asbestos-induced pleural plaques and pulmonary fibrosis
• Hydronephrosis secondary to renal calculus obstruction (July 2024) — managed with nephrostomy
• Cholecystectomy (date unknown)
• Cataracts — recent lens implant (date unknown)
• Bereavement — death of spouse (March 2025)

Drug History:
• Tiolaz Duo eye drops 1 drop to both eyes QDS
• Allopurinol 100mg PO OD
• Rivaroxaban 15mg PO OD
• Doxazosin 2mg PO ON
• Amlodipine 10mg PO OD
• Bisoprolol 5mg PO OD

Recently Stopped Medications:
• None known

Allergy History:
• Unknown — not documented during this clerking

Social History:
Living situation: Lives alone in an assisted living apartment complex in the Torquay area.
Mobility: Reported to walk a couple of times per day. Does not drive (Land Rover observed in belongings but confirmed not driven by patient).
Carers: No formal carers documented. Lives independently. Son (Robert Penn) lives in North Devon; limited recent contact.
Occupation: Retired.
Smoking: Ex-smoker — stopped approximately 7 years ago. Pack-year history not documented.
Alcohol: Not documented.
Functional Status: Previously independent with activities of daily living based on collateral history.

On Examination:
General Appearance: Elderly gentleman, visibly uncomfortable and drowsy. Mask in situ for oxygen delivery.
Observations: HR 66 bpm | BP 101/53 mmHg | RR 26 breaths/min | O2 sats 92% on Optiflow (FiO2 90%, 50L/min) — initially 85% on air at commencement of review
• Cardiovascular: Low-volume regular peripheral pulses. Bilateral pitting oedema to the hips. Heart rate 66 bpm.
• Respiratory: Expiratory polyphonic wheeze throughout. Coarse crepitations to the mid zones bilaterally. RR 26 breaths/min.
• Other: Dry tongue. No further systems formally documented at time of clerking.

Investigations:
• Arterial Blood Gas — on presentation (26/02/2025): pH 7.42, pCO2 3.7, pO2 7.2, Base Excess -5
• Arterial Blood Gas — subsequent (26/02/2025): pH 7.28, pCO2 4.3, pO2 7.5 on 15L O2, Base Excess -10.6, Lactate 4.8, O2 sats 86.3% on gas
• Haemoglobin (26/02/2025): 120 — anaemic since at least December 2024; normal haemoglobin in August 2024
• Platelets (26/02/2025): 221
• Neutrophils (26/02/2025): 9.98 (previously 5.12)
• White Cell Count (26/02/2025): 11.2 (previously 7.2)
• MCV: Normocytic
• Troponin T (26/02/2025): 24 — haemolysed sample, interpret with caution
• Sodium (26/02/2025): 126
• Calcium (26/02/2025): 1.06
• Glucose (26/02/2025): 11.1
• Creatinine (26/02/2025): 113 — at patient's baseline
• Urea (26/02/2025): 9.2
• ALP (26/02/2025): 136 (previously 118)
• Bilirubin (26/02/2025): 68 (baseline 30 — above Gilbert's syndrome baseline)
• ALT (26/02/2025): 112
• CRP (26/02/2025): 6 — no previous CRP on record
• Electrolytes (26/02/2025): Otherwise normal
• MRSA swab (26/02/2025): Negative
• ECG (26/02/2025): Atrial fibrillation with PVCs. QTc 464ms. Biphasic T-waves in V5 and V6. No clear evidence of acute ischaemia. Stable on repeat tracing.
• Chest X-Ray (26/02/2025): Bilateral calcified pleural plaques consistent with asbestos exposure. New bilateral pleural effusions with fluid along the right horizontal fissure. Airspace consolidation in the right middle zone and both lower zones. Enlarged cardiac silhouette. Appearances suggestive of pulmonary oedema; coexisting infective process cannot be excluded.

Impression:
Acute decompensated heart failure, likely secondary to missed myocardial infarction approximately 10 days prior to presentation.
Differential Diagnoses: Coexisting lower respiratory tract infection/pneumonia cannot be excluded given consolidation on CXR and raised white cell count.
Secondary Issues: Metabolic acidosis with elevated lactate suggesting end-organ hypoperfusion. Hyponatraemia. Hypocalcaemia. Haemolysed troponin — repeat required on non-haemolysed sample. Pre-existing asbestos-induced pleural plaques and pulmonary fibrosis may confound respiratory picture. AF with PVCs and prolonged QTc on background of bisoprolol use. CKD stage 3 — caution with diuresis and nephrotoxic agents. Recent bereavement.

Management Plan:
1. Continuous monitoring — cardiac monitoring, hourly observations, strict fluid balance and urine output monitoring.
2. Repeat Troponin T on non-haemolysed sample with serial ECGs to further evaluate for myocardial infarction. Consider cardiology review.
3. Maintain Optiflow high-flow nasal oxygen (FiO2 90%, 50L/min) — titrate to maintain saturations ≥94%. Further IV furosemide for diuresis. Further salbutamol nebulisers prescribed for bronchospasm.
4. Correct electrolyte abnormalities — hyponatraemia and hypocalcaemia to be addressed with appropriate replacement and ongoing monitoring.
5. Bloods to be repeated including repeat ABG, renal function and electrolytes following diuresis.
6. Cardiology review — given likely missed MI with acute decompensated heart failure and new ECG changes.
7. Admission to a Cardiology or Acute Medical bed for ongoing monitoring and management.
8. Escalation plan — to be discussed with patient when clinical condition permits and with next of kin (son, Robert Penn — contact number obtained). Suitability for CPR, ITU and NIV to be formally documented. Patient's wishes and goals of care to be established given age, comorbidities and acuity of presentation.

Summary:

Investigations:

Arterial Blood Gas on presentation (26/02/2025): pH 7.42, pCO2 3.7, pO2 7.2, Base Excess -5. Arterial Blood Gas subsequent (26/02/2025): pH 7.28, pCO2 4.3, pO2 7.5 on 15L O2, Base Excess -10.6, Lactate 4.8, O2 sats 86.3%. Haemoglobin (26/02/2025): 120 (anaemic since at least December 2024; normal August 2024). Platelets (26/02/2025): 221. Neutrophils (26/02/2025): 9.98 (previously 5.12). White Cell Count (26/02/2025): 11.2 (previously 7.2). MCV: Normocytic. Troponin T (26/02/2025): 24 — haemolysed sample. Sodium (26/02/2025): 126. Calcium (26/02/2025): 1.06. Glucose (26/02/2025): 11.1. Creatinine (26/02/2025): 113 (at baseline). Urea (26/02/2025): 9.2. ALP (26/02/2025): 136 (previously 118). Bilirubin (26/02/2025): 68 (baseline 30). ALT (26/02/2025): 112. CRP (26/02/2025): 6. Electrolytes (26/02/2025): Otherwise normal. MRSA swab (26/02/2025): Negative. ECG (26/02/2025): Atrial fibrillation with PVCs, QTc 464ms, biphasic T-waves in V5 and V6, no clear acute ischaemia, stable on repeat. Chest X-Ray (26/02/2025): Bilateral calcified pleural plaques, new bilateral pleural effusions with fluid along right horizontal fissure, airspace consolidation right middle zone and both lower zones, enlarged cardiac silhouette — appearances consistent with pulmonary oedema, coexisting infection possible.

Refined clerking Wed 25 February 2026 19:02

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