Physician's Assistant

Refined clerking Thu 02 April 2026 13:04

Last Modified: 4 days ago

MRN:

Content:

Presenting Complaint:
Oxygen requirement and headache

History of Presenting Complaint:
Brandon is a 26-year-old man who presented with 2 days of back pain, initially in the lower back and then involving the whole body. He developed light-headedness, dizziness, chills, rigours, myalgia, headache, nausea and photophobia. He also reported feeling hot with episodes of sweating overnight and felt unable to get out of bed this morning. Symptoms were worse on waking overnight at around 04:30, when he had excruciating pain and was markedly stiff.

He had returned from holiday in Prague about a week earlier, where he had developed a cold with coryzal symptoms, sneezing and sore throat. A travelling companion also had a cold. He initially thought his symptoms might be related to missing venlafaxine doses, as they felt similar to previous antidepressant withdrawal symptoms. He has improved since arrival and is now able to get up and walk to the toilet, though he remains a little off balance and still has some photophobia.

The A&E team were concerned about meningitis because of headache and photophobia. He is currently requiring 1 L oxygen. He stated he has Ebstein's anomaly and is followed at the Royal Brompton with regular echocardiography.

Past Medical History:
• Ebstein's anomaly
• Depression
• Self-harm, December 2025
• Depression with suicidal ideation, July 2025

Drug History:
• Venlafaxine

Allergy History:
NKDA

Social History:
Lives at home with family.
Previously returned from holiday in Prague 1 week ago.
No recreational drug use reported.

On Examination:
General: Comfortable compared with earlier, able to mobilise to the toilet. Flushed complexion.
Observations: Low-grade pyrexia. 1 L oxygen requirement.
 Cardiovascular: Mechanical-sounding systolic murmur loudest at the tricuspid area, louder on inspiration, query tricuspid regurgitation. No peripheral oedema.
 Respiratory: Chest clear to auscultation.
 Abdomen: Soft and non-tender.
 Neurological: Able to flex chin to chest. No marked meningism. 
 Other: No rash.

Investigations:
 Nasopharyngeal swab: Rhinovirus positive
 CXR: Cardiomegaly; no gross lung lesion; chest clear
 Blood cultures: Normal
 U&Es: Normal
 LFTs: ALT 159, AST 57
 CRP: 23
 Coagulation screen: Normal
 WCC: 9.6
 Neutrophils: 7.36

Impression:
Rhinovirus infection causing systemic viral illness with mild liver injury and oxygen requirement, on a background of cyanotic congenital heart disease (Ebstein's anomaly). Meningitis is unlikely.

Management Plan:
1. Add blood-borne virus screen including EBV, CMV and HIV.
2. Supportive care for rhinovirus infection.
3. Continue to monitor oxygen saturations and try to wean off oxygen.
4. Encourage mobilisation and reassess clinically.
5. Discharge once no longer requiring oxygen and clinically improved.
6. Discussed cardiomegaly on chest X-ray and background Ebstein's anomaly with ongoing Royal Brompton follow-up.

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Summary:

Investigations:

Refined clerking Thu 02 April 2026 13:04

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