Physician's Assistant

Patient Details

Refined clerking (118 days ago 19:45)

Refined clerking Tue 09 December 2025 19:45

Last Modified: 118 days ago

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Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Shortness of breath and chest pain

History of Presenting Complaint:
54-year-old gentleman presented with 5-day history of progressive shortness of breath and chest pain following respiratory clinic review.

Symptoms began 5 days ago with erratic breathing and abdominal discomfort, described as burning epigastric discomfort. Dry cough. Saw Dr Rolin earlier that day and started on a new BD tablet but pt does not recall name.

Symptoms significantly impacting mobility - unable to manage usual activities or walk up hill where he lives.

Similar presentation in February requiring admission.

Past Medical History:
• COPD - latest spirometry (April): FEV1 1.94L (64% predicted), FVC 3.31L (98% predicted), FEV1/FVC ratio 58%, DLCO 70% predicted
• Mixed anxiety and depression
• Cannabis dependence (2020)
• EUPD (2009)
• Eczema (2004)
• Tinnitus
• Previous suicidal ideation
• Gout
• Non-diabetic hyperglycaemia (February 2025)

Drug History:
• Salbutamol inhaler 100mcg 1-2 puffs QDS PRN
• Trimbow 87/5/9mcg 2 puffs BD
• Venlafaxine 75mg PO BD
• Ezetemibe 10mg PO OD

Allergy History:
• Statins - intolerance
• Multiple food allergies

Social History:
Lives alone in flat. Ex-smoker (quit 3 years ago after 40 cigarettes daily for 40 years). Minimal alcohol intake. Enjoys sea fishing when able. Functional status significantly impacted by breathlessness.

On Examination:
General Appearance: Alert, appears unwell, tachycardic
Observations: Initial - RR 28, Sats 96%, HR 106, BP 123/88, Temp 36.9°C. Improved to RR 17, HR 94, BP 117/80, Temp 36.8°C, Sats 98% on air
• Cardiovascular: Tachycardic, no murmurs audible
• Respiratory: Chest clear (post-nebulisers), no wheeze, good air entry bilaterally
• Other: No peripheral oedema, slim build

Investigations:
• Lateral flow test: Negative
• COVID swab: Negative
• Influenza swab: Negative
• Chest X-ray: Long-standing elevation left hemidiaphragm, left hilar contour enlarged (possibly rotational), no consolidation or pleural effusion
• Creatinine: 135 (baseline 111)
• CRP: 15 (previously 15 on 04/12 and 08/12)
• Urea: 5.4
• AST: Normal
• LFTs: Normal
• INR: 1.0
• WCC: 11.2 (Neutrophils 8.85)
• ECG: Sinus tachycardia, nil ischaemic
• D-dimer: Pending

Impression:
Exacerbation of COPD (likely non-infective) versus Pulmonary Embolism
Burning retrosternal chest pain - Possible gastro-oesophageal reflux disease

Management Plan:
1. Trial omeprazole for GORD symptoms
2. Await D-dimer result to guide further management
3. If D-dimer positive: CTPA and LMWH
4. If D-dimer negative: manage as COPD exacerbation with oral steroids
5. Given not requiring oxygen, could discharge home with oral steroids and safety-netting if D-dimer negative
6. If hospital admission required: treatment dose LMWH until scan
7. Respiratory team review
8. Full escalation

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Refined clerking Tue 09 December 2025 19:45

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