Physician's Assistant

Patient Details

Refined clerking (191 days ago 06:27)

Refined clerking Sat 27 September 2025 06:27

Last Modified: 191 days ago

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Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Low blood pressure and tachycardia

History of Presenting Complaint:
Patient transferred from Newton Abbot Community Hospital with hypotension and tachycardia. She had been resident at the community hospital recovering from recent pneumonia when staff noted SBP 80 and ECG showing AF with fast VR. Managed with IVI initially with no improvement in BP. Loaded on digoxin 500mcg total.

Patient reports feeling generally unwell but without specific symptoms of infection. Frustrated about having a urinary catheter, which she states she never wanted. The catheter was initially inserted for urinary retention. Catheter blocked, bypassing, changed this morning.

She has been struggling with poor appetite and weight loss, reporting difficulty accessing adequate nutrition in hospital

Pressure sore on sacrum.

Past Medical History:
• Right parietal lobe cerebral abscess with right frontal craniotomy (June 2024)
• Focal onset epilepsy
• Residual left hemiparesis
• Hypertension
• Recent pneumonia with left-sided consolidation

Drug History:
• Levetiracetam 1g PO BD
• Sodium valproate 200mg PO mane, 400mg PO nocte
• Senna 15mg PO nocte

Social History:
Lives in independent living flat in Totnes. Limited mobility - wheelchair bound due to residual hemiparesis from previous neurosurgery, seizures and abscess.
Lives alone but has carer support for personal care.

On Examination:
General Appearance: Thin, alert but appears dehydrated
Observations: HR 76, BP 58/46, Temp 37.4°C, RR 21, SATS 96%, EWS 5
• Cardiovascular: Normal heart sounds, no murmurs detected
• Respiratory: Chest sounds clear on anterior examination
• Neurological: Left-sided weakness at baseline.
• Skin: Pressure sore noted on buttocks with some surrounding erythema, dressed
• General: Dry mucous membranes suggesting dehydration

Investigations:
• Sodium: 131 (previously 133, lowest 123 in January)
• Creatinine: 56 (baseline 41 pre-AKI)
• Troponin: 14 (previously 109 in September)
• Urea: 6.2
• INR: 0.9
• Full blood count: Normal
• Calcium: Normal
• Venous blood gas: Reassuring
• Blood cultures: Negative so far
• AST: Haemolysed sample
• Echocardiogram (January 2025): Bedside echo showed systolic anterior motion of AMVL with significant LVOT obstruction, velocity 4.41 m/s, at least moderate MR, dilated LA, normal LV systolic function
• ECG (26th): Atrial fibrillation with rapid ventricular response, non-sustained ventricular tachycardia

Impression:
Atrial fibrillation with rapid ventricular response secondary to possible urinary tract infection
- Feel majority of hypotension related to arrythmia as opposed to infection
Pressure sore possibly infected
Clinically dry

Management Plan:
1. IV fluids
2. CSU for MC&S
3. Chest X-ray
4. Wound swab from pressure sore
5. Antibiotics to treat UTI - started on Tazocin so can continue
6. TWOC once medically stable if patient wishes
7. IO monitoring
8. AMU
9. Dietetic review
10. Loaded on digoxin which has controlled rate in CH - to continue regularly

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Refined clerking Sat 27 September 2025 06:27

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