Physician's Assistant

Patient Details

Refined clerking (8 days ago 16:09)

Refined clerking Sun 29 March 2026 16:09

Last Modified: 8 days ago

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Content:

Presenting Complaint:
Vomiting, shortness of breath.

History of Presenting Complaint:
82-year-old lady from a nursing home with sudden onset unwellness, vomiting and shortness of breath. On review, she had not had any further vomiting since admission and denied chest pain or ongoing shortness of breath. History from the nursing home and initial assessment suggested dehydration and infection. She was noted to have marked abdominal distension with tympany and constipation, with last bowel motion about a week ago. Urine output had been poor in the nursing home.

Past Medical History:
• Severe frailty, CFS 7
• Pressure ulcers, 2023
• Gallstones, 2022
• Knee osteoarthritis, 2021
• Type 2 diabetes mellitus, 2021
• CKD stage 3b
• Hypertension
• Hypothyroidism
• Schizophrenia
• Previous stroke with left-sided weakness

• Diabetes mellitus - latest HbA1c: 57 mmol/mol (13/03/2026)

Drug History:
• Furosemide 40mg PO BD
• Metformin 500mg PO OD
• Laxido PO OD
• Paracetamol PO PRN
• Clonazepam 1mg PO nocte
• Fluoxetine 20mg PO BD
• Aripiprazole 15mg PO OD
• Senna 15mg PO nocte PRN
• Lansoprazole 30mg PO OD
• Levothyroxine 100 micrograms PO OD

Allergy History:
• NKDA

Social History:
Lives in a nursing home.

On Examination:
Unwell on presentation. Febrile and hypoxic on air.
Observations:: HR 125, BP 170/90, Temp 40°C, RR 28, O2 sats 77% on air.
• Abdomen: Markedly distended and tympanic with reduced bowel motion suspected; no clear obstruction on initial assessment.
• Respiratory: Chest clear on auscultation.
• Other: Right leg erythematous, warm and swollen to mid-calf with previous ulcers noted. Mucous membranes dry. Catheter in situ initially, later removed on request.

Investigations:
• Blood cultures: Negative so far
• Chest X-ray: Pulmonary plethora; no major collapse or consolidation identified
• Coagulation screen: Normal
• Creatinine: 117 (baseline 94)
• Sodium: 131 (baseline 134)
• Potassium: Normal
• CRP: 27 (previously 11)
• Urea: Normal
• Hb: 121
• Neutrophils: 8.53 (previously 3.17)
• WCC: 10.1 (previously 5.4)
• Venous gas pH: 7.42
• Venous gas sodium: 130
• Capillary blood glucose: 0.3
• Previous microbiology of leg ulcers: Staphylococcus aureus, susceptible to clarithromycin, doxycycline and flucloxacillin, resistant to penicillin
• Urine culture (October 2025): Negative
• HbA1c (13/03/2026): 57 mmol/mol

Impression:
Hospital-acquired pneumonia versus viral infection, with concurrent right leg cellulitis, dehydration, constipation and acute kidney injury on CKD. Urinary tract infection to be excluded.

Management Plan:
1. IV fluids.
2. IV antibiotics.
3. Quad swab and urine MC&S.
4. Add TSH to blood tests.
5. Hold furosemide and lansoprazole while treated for infection.
6. If hyponatraemia worsens despite fluids, check urine osmolality, urine sodium and review fluid status daily.
7. Daily U&Es while in AKI.
8. If AKI worsens, consider renal ultrasound.
9. Abdominal X-ray to assess for obstruction.
10. Start laxatives to relieve constipation.
11. Catheter removed.
12. Transfer to acute medical unit.

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Refined clerking Sun 29 March 2026 16:09

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