Physician's Assistant

Clerking Mon 16 June 2025 18:29

Last Modified: 283 days ago

MRN:

Content:

Medical ST4 Miller Clerking

Presenting Complaint:
Shortness of breath

History of Presenting Complaint:
6-month history of recurrent chest infections requiring multiple courses of antibiotics and steroids. 
Initially well until Christmas, then developed persistent productive cough with green-yellow sputum. 
Had significant deterioration in exercise tolerance - previously able to walk 3 miles without stopping in November, now struggles with 40 steps to front door. 
Recent travel to South Africa and Sri Lanka with marked worsening at altitude and during flights. Has had 3-4 courses of prednisolone over past 6 months. 
Recent course of levofloxacin caused Achilles tendon partial rupture.
Currently on oxygen with improvement in symptoms and colour. 
Bilateral leg swelling developed during holidays, right leg improved with compression stockings but left leg remains swollen.
Nil chest pain

Past Medical History:
• Allergic asthma diagnosed age 16
• Achilles tendonitis secondary to levofloxacin (4 weeks ago)
• Recent diagnosis of diabetes (HbA1c elevated into diabetic range)
• Multiple previous fractures from cricket (fingers, ribs, thumbs)

Medication History:
• Salbutamol inhaler
• Tiotropium inhaler
• Prednisolone 30mg PO OD (recently completed 5-day course)
• Metformin (recently commenced for diabetes)
• Compression stockings PRN

Allergic History:
Dust mites
Levofloxacin (tendonitis)

Social History:
Lives in Cornwall. Retired primary school teacher. Previously very active - regular 3-mile walks. Ex-smoker (5 cigarettes daily for 3-5 years, ceased many years ago). Social alcohol intake. Recently travelled to South Africa and Sri Lanka. Currently housebound due to breathlessness.

On Examination:
Sat 75% on room air, improved to 95-96% on oxygen 5L RR 21 BP 119/90 HR 91 T 37.0
Bilateral lower limb oedema - right to mid-shin, left more extensive
Hands show evidence of previous cricket injuries
No wheeze audible
Improved colour and breathing on oxygen

Investigations:
Sputum cultures: Haemophilus influenzae (intermittent growth) - most recent clear of H influenzae. Sensitive to doxycycline
Chest X-ray requested
Blood tests requested
CT pulmonary angiogram planned
Echocardiogram requested
BNP requested

Impression:
Most likely recurrent infective exacerbation of bronchiectasis secondary to atypical bacterial or fungal pathogen. 
Rule out concomitant CCF, pulmonary embolism and malignancy as cause of respiratory deterioration.

Plan:
1. Admit to respiratory ward [_]
2. Chest X-ray to exclude pneumonia [_]
3. CT pulmonary angiogram if chest X-ray clear [_]
4. Echocardiogram and BNP to assess cardiac function [_]
5. Blood tests including FBC, U&E, CRP, BNP [_]
6. Commence anticoagulation pending CT-PA result [_]
7. Commence appropriate antibiotic based on microbiology sensitivities [_]
8. Continue prednisolone course [_]
9. Nebulised bronchodilators and mucolytics [_]
10. Oxygen therapy to maintain sats 94-96% [_]
11. Respiratory ward - can go to resp bed prior to AMU PTWR.

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Summary:

Investigations:

Clerking Mon 16 June 2025 18:29

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