Physician's Assistant

Refined clerking Sat 28 March 2026 09:35

Last Modified: 9 days ago

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Medical ST5 Miller Clerking
Sat 28 March 2026 09:35

Presenting Complaint:
Shortness of breath

History of Presenting Complaint:
85-year-old lady with a background of COPD, HFrEF and recent chest infection. She had been reviewed in the community with reduced oral intake, dark urine and possible back pain, and was taking oral amoxicillin. Over the preceding 2 weeks she and her daughter had both had a chest infection. She became more short of breath and there was concern she was fluid overloaded, with possible community-acquired pneumonia, in the context of significant frailty and poor mobility at home. Her daughter had moved in to care for her and was struggling with the physical burden. There was discussion with the frailty team and hospital-at-home services, but there was no carer support available at home, so she was admitted for further management. On review she reported feeling improved and denied current cough, fever or oxygen requirement. She noted mild leg swelling, left greater than right.

Past Medical History:
• COPD
• Small segmental pulmonary embolism, November 2025
• Stroke, 2023
• Housebound since 2021
• Heart failure with reduced ejection fraction following anterior ST-elevation myocardial infarction, 2021
• Primary PCI with 2 stents, 2021
• Oesophagitis
• Hiatus hernia
• Essential hypertension
• CKD stage 3

Drug History:
• Melatonin modified-release 2mg PO nocte
• Colecalciferol 3mg PO OD
• Clopidogrel 75mg PO OD
• Dapagliflozin 10mg PO OD
• Ramipril 1.25mg PO nocte
• Atorvastatin 20mg PO OD
• Furosemide 40mg PO breakfast and 40mg PO lunchtime
• Lansoprazole 30mg PO OD
• Aspirin 75mg PO OD

Allergy History:
• No known drug allergies

Social History:
Lives at home with her daughter, who has recently moved in and is providing sole care. She is functionally limited and struggles with transfers, including getting on to the commode, and is effectively housebound. No formal carers available at present.

On Examination:
Alert and conversant. 
Observations: Stable; no oxygen requirement.
• Cardiovascular: Heart sounds normal. Pitting oedema to both knees.
• Respiratory: Bibasal crepitations, right more coarse than left.

Investigations:
• Bloods: CRP 11, Plt high

Impression:
Shortness of breath, likely multifactorial with resolving respiratory infection, possible fluid overload and significant frailty.
Medically suitable for discharge
Carer burnout

Management Plan:
1. Chest X-ray
2. Increase furosemide.
3. Continue oral antibiotics with doxycycline to cover atypical organisms.
4. Review medically for discharge once improved.
5. OT/JETS review and package of care to support discharge home and reduce carer burden.

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Investigations:

Refined clerking Sat 28 March 2026 09:35

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