Physician's Assistant

Patient Details

Refined clerking (4 days ago 17:33)

Refined clerking Thu 02 April 2026 17:33

Last Modified: 4 days ago

MRN:

Content:

Presenting Complaint:
Cough and catarrh

History of Presenting Complaint:
He reported a 5-week history of nasal congestion with watery discharge that would not clear despite antibiotics and nasal sprays. Over the subsequent 3 weeks he developed a cough with productive sputum, which is initially thick and white but becomes clear. He has been waking at 01:00 to 02:00 because of breathlessness and has had to sit up and expectorate into a container. He also described a new chest rash over the last few days, with some discomfort over the affected area. He denied trauma, falls, use of a radiator or electric heat lamp, and said he has only been using a heated pad on his neck for a sore shoulder. He reported altered bowel habit with straining, passage of dark black stools that stick to the toilet bowl, and a feeling of incomplete evacuation. This is associated with some abdominal discomfort on straining but no pain at other times. He denied haematemesis, presyncope, or weight loss. He felt the symptoms were similar to previous episodes of upper gastrointestinal discomfort and had had previous endoscopies, most recently in September.

Past Medical History:
• COPD
• Previous endoscopies
• Chronic shoulder pain under physiotherapy review

Drug History:
• Inhaler PRN

Allergy History:
• No known drug allergies stated

Social History:
Lives at home.  
Current smoker, approximately 15 cigarettes per day, smoking for around 60 years.  
Drinks alcohol only when on holiday, approximately twice a year; none since September.

On Examination:
Appeared mildly unwell.  
Observations: not stated.  
Abdomen: soft, non-tender.  
Cardiovascular: normal on brief assessment.  
Respiratory: chest slightly wheezy.  
Other: rash over the chest with reticular erythematous pattern, also some rash on the lower back.

Investigations:
• WCC: raised
• Neutrophils: raised
• Chest X-ray: requested

Impression:
Acute exacerbation of COPD, likely infective trigger.  
Reticular erythematous chest rash, likely related to heat pad use.  
Constipation with dark stools, not suggestive of melaena on the history given.

Management Plan:
1. Treat COPD exacerbation with a course of steroids and antibiotics.
2. Arrange chest X-ray to assess for infection or pneumonia.
3. Give laxatives for constipation and encourage bowel clearance.
4. Advise avoidance of heat pad use over the chest; monitor rash.
5. Encourage smoking cessation and arrange GP review for inhaler optimisation and lung function testing.
6. Advise GP review for persistent shoulder symptoms if physiotherapy has not helped.

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:

Patient Details

Refined clerking Thu 02 April 2026 17:33

Field Clipboard (for EPR paste)

Tasks

Feedback