Physician's Assistant

Patient Details

Refined clerking (137 days ago 20:17)

Refined clerking Thu 20 November 2025 20:17

Last Modified: 137 days ago

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Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Chest pain

History of Presenting Complaint:
This 56-year-old gentleman presented with ongoing refractory cardiac-sounding chest pain. 
Nausea but no vomiting
Pain easing with isoket infusion
Longstanding cardiac history

Past Medical History:
• Extensive cardiac history with refractory angina
• Inferior MI (2009)
• PCI to RCA, OM and LAD
• Significant diffuse LAD disease not amenable to revascularisation
• Coronary sinus reducer implant (November 2021) - worked well for approximately 6 months
• DDDR permanent pacemaker
• Type 2 diabetes mellitus - latest HbA1c: 58 mmol/mol
• Epilepsy - likely complex partial
• Hypothyroidism
• Lacunar infarction (June 2025)
• Benign prostatic hypertrophy
• Atony of bladder
• Essential hypertension

Drug History:
• Bisoprolol 7.5mg PO OD
• Isosorbide mononitrate 240mg PO OM (4 tablets as per Cardiology)
• Glyceryl trinitrate 400mcg sublingual spray PRN
• Clopidogrel 75mg PO OD
• Lansoprazole 15mg PO OD
• Atorvastatin 80mg PO ON
• Ramipril 1.25mg PO OD
• Nicorandil 10mg PO BD
• Nicorandil 20mg PO BD
• Ivabradine 5mg PO BD
• Uniphyllin 200mg PO BD
• Ranolazine 750mg PO BD
• Metformin 1g PO BD
• Dapagliflozin 10mg PO OD
• Toujeo insulin as directed
• Dulaglutide 1.5mg SC weekly
• Levetiracetam 750mg PO BD
• Epilim Chrono 1200mg PO BD (500mg BD + 200mg BD)
• Sertraline 75mg PO OD
• Mirtazapine 15mg PO ON
• Gabapentin 600mg PO TDS
• Levothyroxine 150mcg PO OD (100mcg + 50mcg)
• Furosemide 40mg PO OM
• Tamsulosin 400mcg PO OD
• Docusate 100mg PO TDS

Allergy History:
• Tramadol - causes generalised rash

Social History:
Lives at home with wife and 26-year-old daughter. Family history of cardiac disease on maternal side. 
No smoking or alcohol.

On Examination:
Observations: HR 60, BP 128/85, O2 sats 92% on air
Chest clear
HS normal
Abdomen obese but SNT
No peripheral oedema. 
Not diaphoretic
ECG Lateral TWI, paced. No dynamic changes.

Investigations:
• Troponin T: 5
• Liver function tests: ALP 141 (previously normal), otherwise normal
• CRP: 3
• Urea: 5.1
• Full blood count: unremarkable
• Chest X-ray: yet to be performed
• HbA1c: 58 mmol/mol

Impression:
Refractory angina with acute exacerbation requiring admission

Management Plan:
1. CCU
2. Titrate isoket to pain
3. Morphine and antiemetic for pain and nausea
4. Serial troponins
5. Cardiology review mane
6. Full escalation

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Refined clerking Thu 20 November 2025 20:17

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