Physician's Assistant

Refined clerking Sat 04 April 2026 20:47

Last Modified: 2 days ago

MRN:

Content:

[TITLE: "Medical ST5 Miller Clerking"]
04/04/2026 20:47

Presenting Complaint:
Headache and visual disturbance

History of Presenting Complaint:
Brandon is a 26-year-old man who presented with a 2-day history of back pain, initially in the lower back, with associated light-headedness and dizziness. The pain then worsened and became more generalised, with whole-body aches, stiffness, feeling cold, nausea, headache and photophobia. He reported chills and night sweats. He also had some abdominal discomfort. This morning he was unable to get out of bed, but later in the day he improved and was able to walk to the toilet. He had recently returned from a trip to Prague and had had a preceding coryzal illness with sore throat, sneezing and a cold after the flight. One of his travel companions was also unwell with a cold. He was initially reviewed by the ED team because of concern regarding meningitis due to headache, photophobia and neck stiffness.

Past Medical History:
• Ebstein's anomaly, under follow-up at the Royal Brompton with regular echocardiography
• Depression
• Previous self-harm and suicidal ideation presentations to ED in December 2025 and July 2025

Drug History:
• Venlafaxine PO

Allergy History:
• NKDA

Social History:
Lives at home with family. Recently returned from holiday in Prague. No alcohol or recreational drug history reported.

On Examination:
Alert and more comfortable than earlier. Low-grade fever reported by nursing staff. No meningism. Chest clear on auscultation. Mechanical-sounding systolic murmur loudest at the tricuspid area, louder on inspiration, query tricuspid regurgitation. Abdomen soft and non-tender. No peripheral oedema. No rash. Required 1 L oxygen.

Investigations:
• Nasopharyngeal swab: Rhinovirus positive
• Chest X-ray: Cardiomegaly; no gross lung lesion
• Blood cultures: Normal
• Urea and electrolytes: Normal
• Liver function tests: ALT 159, AST 57
• CRP: 23
• Coagulation screen: Normal
• White cell count: 9.6
• Neutrophils: 7.36
• Blood borne virus screen including CMV, EBV and HIV: requested

Impression:
Rhinovirus infection on a background of cyanotic congenital heart disease with oxygen requirement. Mild liver injury. Meningitis felt unlikely clinically.

Management Plan:
1. Supportive care for rhinovirus infection.
2. Continue oxygen and monitor saturations; attempt to wean off oxygen.
3. Repeat blood tests and add blood borne virus screen including CMV, EBV and HIV.
4. Encourage mobilisation and monitor clinical progress.
5. Discharge once no longer requiring oxygen and clinically improved.
6. Patient to continue follow-up with the Royal Brompton for Ebstein's anomaly and regular echocardiography.

Field Clipboard (for EPR paste)

Builds copy buttons from the headings currently in the note, and also lets you copy the entire note.

Summary:

Investigations:

Refined clerking Sat 04 April 2026 20:47

Field Clipboard (for EPR paste)

Tasks

Feedback