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Notes (2 days ago 16:07)

Notes Sat 04 April 2026 16:07

Last Modified: 2 days ago

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Clinical Note

Hx:
Brandon Brooks, 26-year-old man, admitted with headache, back pain, dizziness, photophobia, nausea and low-grade fevers following a recent viral upper respiratory tract illness after travel to Prague. He reported onset of mild lower back pain on Tuesday, with progression over the following 24 hours to marked myalgia, rigors, chills, sweats, dizziness, and severe headache. He also described transient visual disturbance and mild neck stiffness. Symptoms were worse overnight, and he was initially unable to mobilise, but is now significantly improved and able to walk to the toilet. He denied vomiting. He had some abdominal discomfort earlier, now improved.

Background:
- Recent holiday in Prague with cold-like symptoms including coryza, sneezing and sore throat.
- Previous ED attendances in December 2025 with self-harm using a razor blade and in July 2025 with depression and suicidal ideation.
- Patient stated he has Ebstein's anomaly and is under follow-up at the Royal Brompton with regular echocardiography.

Ix:
- Nasopharyngeal swab: Rhinovirus positive.
- Chest X-ray: Cardiomegaly; lungs clear.
- Blood cultures: Normal.
- Urea and electrolytes: Normal.
- LFTs: ALT 159, AST 57.
- CRP 23.
- FBC: WCC 9.6, neutrophils 7.36, neutrophilia.
- Coagulation screen: Normal.
- Blood gas/observations: 1L oxygen requirement; low-grade fevers.

O/E:
- Appeared flushed.
- Neck: Mild stiffness, but chin could be brought to chest.
- No focal meningeal signs.
- Chest: Clear to auscultation.
- Cardiovascular: Mechanical-sounding systolic murmur loudest at the tricuspid area, louder on inspiration, query tricuspid regurgitation.
- Abdomen: Soft, non-tender.
- No peripheral oedema.
- No rash.

Impression:
- Rhinovirus infection with mild hypoxic respiratory requirement.
- Mild transaminitis, likely secondary to viral infection.
- Meningitis felt unlikely clinically.
- Background cyanotic congenital heart disease, likely Ebstein's anomaly, with cardiomegaly on CXR.

Plan:
- Supportive care.
- Add blood-borne virus screen including EBV, CMV and HIV.
- Continue oxygen and monitor saturations.
- Encourage mobilisation and trial off oxygen.
- Discharge once no longer requiring oxygen and clinically improved.
- Patient to continue follow-up with Royal Brompton for cardiac surveillance.

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Notes (2 days ago 16:10)

Notes Sat 04 April 2026 16:10

Last Modified: 2 days ago

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Clinical Note

Patient: Brendan, 26-year-old man.

Presentation
Reviewed by the medical registrar after A&E assessment for headache, photophobia, back pain, dizziness, and reduced exercise tolerance. Symptoms began with mild lower back pain on Tuesday, then worsened over the following day with rigors, whole-body aches, nausea, headache, and light sensitivity. He also reported feeling cold, sweaty at night, and initially unable to get out of bed. Symptoms have improved significantly by review, with ability to mobilise to the toilet and overall feeling much better.

Hx
He had returned from holiday in Prague shortly before onset of symptoms and had also recently had a coryzal illness with sore throat, sneezing, and cold-like symptoms, which had improved. He wondered whether he had missed doses of venlafaxine, as the dizziness felt similar to previous antidepressant withdrawal symptoms. No vomiting. No rash. No other household contacts unwell. No recreational drug use reported.

Past medical history
Two previous ED attendances in December 2024 and July 2025 for self-harm, deliberate self-harm with a razor blade, depression, and suicidal ideation.

Drug history
Venlafaxine.

Examination
Alert and clinically improved. Mild photophobia. Neck supple, with chin to chest possible. Chest clear to auscultation. Soft, non-tender abdomen. No peripheral oedema. No rash.

Auscultation revealed a mechanical systolic murmur, loudest at the tricuspid area and on inspiration, query tricuspid regurgitation. Patient reported known Ebstein's anomaly and regular follow-up at the Royal Brompton with echocardiography.

Ix
Rhinovirus positive on nasopharyngeal swab.
Chest X-ray: cardiomegaly, no gross lung lesion.
Blood cultures: normal.
U&Es: normal.
LFTs: ALT 159, AST 57.
CRP 23.
Coagulation screen: normal.
FBC: white cells 9.6, neutrophils 7.36, neutrophilia.
Urea: normal.

Impression
Rhinovirus infection causing systemic symptoms and mild liver injury, with transient oxygen requirement. Meningitis felt unlikely on clinical grounds. Cardiomegaly in the context of known cyanotic congenital heart disease/Ebstein's anomaly.

Plan
- Supportive care.
- Add blood-borne virus screen, including EBV, CMV, and HIV.
- Monitor oxygen saturations and encourage mobilisation.
- Discharge once no longer requiring oxygen and clinically stable.
- Continue follow-up with the Royal Brompton for Ebstein's anomaly.

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Refined clerking (2 days ago 20:46)

Refined clerking Sat 04 April 2026 20:46

Last Modified: 2 days ago

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Presenting Complaint:
Headache and visual disturbance

History of Presenting Complaint:
Brandon was reviewed after presenting with back pain, headache, photophobia, dizziness and lightheadedness, with associated feverishness, rigors and myalgia. Symptoms began on Tuesday with mild lower back ache, initially thought to be related to missing antidepressant medication, then worsened yesterday with increasing back pain, generalized aches, feeling cold, sweating at night, nausea, headache and sensitivity to light. This morning he was unable to get out of bed, but by the time of review he felt much better, was able to walk to the toilet and had no ongoing significant pain. He had recently returned from holiday in Prague, where he had developed coryzal symptoms including sore throat, sneezing and a cold, which had improved before the current illness. He lives at home with family. The admitting team were concerned about meningitis because of photophobia and headache, but neck stiffness was mild and his symptoms had improved significantly. He also reported a history of cyanotic congenital heart disease, later clarified as Ebstein's anomaly, with regular follow-up at the Royal Brompton and echocardiography.

Past Medical History:
• Ebstein's anomaly
• Cyanotic congenital heart disease
• Depression
• Self-harm with razor blade, December 2025
• Depression and suicidal ideation, July 2025

Drug History:
• Venlafaxine

Allergy History:
NKDA

Social History:
Lives at home with family. 
Independent mobilisation; initially unable to get out of bed this morning but later able to walk to the toilet. 
Recently returned from holiday in Prague. 
No recreational drug use reported. 
No alcohol history provided.

On Examination:
Alert, comfortable and improved from earlier in the day. Mild facial flushing. 
Observations: Low-grade fever; oxygen requirement 1 L via nasal cannula.
• Abdomen: Soft and non-tender.
• Cardiovascular: Mechanical-sounding systolic murmur loudest in the tricuspid area, louder on inspiration, query tricuspid regurgitation. No peripheral oedema.
• Respiratory: Chest clear to auscultation. 
• Neurological: Able to flex neck so chin reached chest; mild stiffness only. 
• Other: No rash.

Investigations:
• Nasopharyngeal swab: Rhinovirus positive
• Chest X-ray: Cardiomegaly; no gross lung lesion
• Blood cultures: Normal
• U&Es: Normal
• LFTs: ALT 159, AST 57
• CRP: 23
• Coagulation screen: Normal
• FBC: WCC 9.6, neutrophils 7.36

Impression:
Rhinovirus infection on a background of cyanotic congenital heart disease with mild liver injury and transient oxygen requirement. Meningitis felt unlikely clinically.

Management Plan:
1. Supportive care for rhinovirus infection.
2. Add blood-borne virus screen including EBV, CMV and HIV.
3. Monitor oxygen saturations and wean oxygen as tolerated.
4. Repeat/continue blood tests as arranged.
5. Mobilise and assess for discharge once no longer requiring oxygen.
6. Discussed examination findings and cardiomegaly on chest X-ray with the patient; advised follow-up with the Royal Brompton for known Ebstein's anomaly.

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Refined clerking (2 days ago 20:47)

Refined clerking Sat 04 April 2026 20:47

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[TITLE: "Medical ST5 Miller Clerking"]
04/04/2026 20:47

Presenting Complaint:
Headache and visual disturbance

History of Presenting Complaint:
Brandon is a 26-year-old man who presented with a 2-day history of back pain, initially in the lower back, with associated light-headedness and dizziness. The pain then worsened and became more generalised, with whole-body aches, stiffness, feeling cold, nausea, headache and photophobia. He reported chills and night sweats. He also had some abdominal discomfort. This morning he was unable to get out of bed, but later in the day he improved and was able to walk to the toilet. He had recently returned from a trip to Prague and had had a preceding coryzal illness with sore throat, sneezing and a cold after the flight. One of his travel companions was also unwell with a cold. He was initially reviewed by the ED team because of concern regarding meningitis due to headache, photophobia and neck stiffness.

Past Medical History:
• Ebstein's anomaly, under follow-up at the Royal Brompton with regular echocardiography
• Depression
• Previous self-harm and suicidal ideation presentations to ED in December 2025 and July 2025

Drug History:
• Venlafaxine PO

Allergy History:
• NKDA

Social History:
Lives at home with family. Recently returned from holiday in Prague. No alcohol or recreational drug history reported.

On Examination:
Alert and more comfortable than earlier. Low-grade fever reported by nursing staff. No meningism. Chest clear on auscultation. Mechanical-sounding systolic murmur loudest at the tricuspid area, louder on inspiration, query tricuspid regurgitation. Abdomen soft and non-tender. No peripheral oedema. No rash. Required 1 L oxygen.

Investigations:
• Nasopharyngeal swab: Rhinovirus positive
• Chest X-ray: Cardiomegaly; no gross lung lesion
• Blood cultures: Normal
• Urea and electrolytes: Normal
• Liver function tests: ALT 159, AST 57
• CRP: 23
• Coagulation screen: Normal
• White cell count: 9.6
• Neutrophils: 7.36
• Blood borne virus screen including CMV, EBV and HIV: requested

Impression:
Rhinovirus infection on a background of cyanotic congenital heart disease with oxygen requirement. Mild liver injury. Meningitis felt unlikely clinically.

Management Plan:
1. Supportive care for rhinovirus infection.
2. Continue oxygen and monitor saturations; attempt to wean off oxygen.
3. Repeat blood tests and add blood borne virus screen including CMV, EBV and HIV.
4. Encourage mobilisation and monitor clinical progress.
5. Discharge once no longer requiring oxygen and clinically improved.
6. Patient to continue follow-up with the Royal Brompton for Ebstein's anomaly and regular echocardiography.

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Refined clerking (4 days ago 13:04)

Refined clerking Thu 02 April 2026 13:04

Last Modified: 4 days ago

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Presenting Complaint:
Oxygen requirement and headache

History of Presenting Complaint:
Brandon is a 26-year-old man who presented with 2 days of back pain, initially in the lower back and then involving the whole body. He developed light-headedness, dizziness, chills, rigours, myalgia, headache, nausea and photophobia. He also reported feeling hot with episodes of sweating overnight and felt unable to get out of bed this morning. Symptoms were worse on waking overnight at around 04:30, when he had excruciating pain and was markedly stiff.

He had returned from holiday in Prague about a week earlier, where he had developed a cold with coryzal symptoms, sneezing and sore throat. A travelling companion also had a cold. He initially thought his symptoms might be related to missing venlafaxine doses, as they felt similar to previous antidepressant withdrawal symptoms. He has improved since arrival and is now able to get up and walk to the toilet, though he remains a little off balance and still has some photophobia.

The A&E team were concerned about meningitis because of headache and photophobia. He is currently requiring 1 L oxygen. He stated he has Ebstein's anomaly and is followed at the Royal Brompton with regular echocardiography.

Past Medical History:
• Ebstein's anomaly
• Depression
• Self-harm, December 2025
• Depression with suicidal ideation, July 2025

Drug History:
• Venlafaxine

Allergy History:
NKDA

Social History:
Lives at home with family.
Previously returned from holiday in Prague 1 week ago.
No recreational drug use reported.

On Examination:
General: Comfortable compared with earlier, able to mobilise to the toilet. Flushed complexion.
Observations: Low-grade pyrexia. 1 L oxygen requirement.
 Cardiovascular: Mechanical-sounding systolic murmur loudest at the tricuspid area, louder on inspiration, query tricuspid regurgitation. No peripheral oedema.
 Respiratory: Chest clear to auscultation.
 Abdomen: Soft and non-tender.
 Neurological: Able to flex chin to chest. No marked meningism. 
 Other: No rash.

Investigations:
 Nasopharyngeal swab: Rhinovirus positive
 CXR: Cardiomegaly; no gross lung lesion; chest clear
 Blood cultures: Normal
 U&Es: Normal
 LFTs: ALT 159, AST 57
 CRP: 23
 Coagulation screen: Normal
 WCC: 9.6
 Neutrophils: 7.36

Impression:
Rhinovirus infection causing systemic viral illness with mild liver injury and oxygen requirement, on a background of cyanotic congenital heart disease (Ebstein's anomaly). Meningitis is unlikely.

Management Plan:
1. Add blood-borne virus screen including EBV, CMV and HIV.
2. Supportive care for rhinovirus infection.
3. Continue to monitor oxygen saturations and try to wean off oxygen.
4. Encourage mobilisation and reassess clinically.
5. Discharge once no longer requiring oxygen and clinically improved.
6. Discussed cardiomegaly on chest X-ray and background Ebstein's anomaly with ongoing Royal Brompton follow-up.

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Refined clerking (2 days ago 21:33)

Refined clerking Sat 04 April 2026 21:33

Last Modified: 2 days ago

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Medical ST5 Miller Clerking
04/04/2026 21:33

Presenting Complaint:
Fever, headache and visual disturbance

History of Presenting Complaint:
Brandon is a young adult man admitted with a 2-day history of back pain, initially in the lower back and right-sided lower back, which then worsened and spread to involve his whole body. He developed lightheadedness, dizziness, chills, rigours, sweats, nausea, photophobia and a pounding headache. He also reported feeling hot to touch and was unable to get out of bed this morning, but is now able to mobilise to the toilet and feels significantly better.

He returned from holiday in Prague a week ago and had a preceding coryzal illness with sneezing, sore throat and cold-like symptoms after travel, which he felt may have been related to an illness caught on the plane. A travelling companion also had a cold. There is no history of vomiting. No rash was reported. The A&E team were concerned about meningitis because of his headache, photophobia and systemic symptoms.

Past Medical History:
• Ebstein’s anomaly, under follow-up at the Royal Brompton with regular echocardiography
• Depression
• Self-harm, December 2025
• Depression with suicidal ideation, July 2025

Drug History:
• Venlafaxine PO

Allergy History:
• NKDA

Social History:
Lives at home with family.

On Examination:
Alert and more comfortable than earlier, mobilising independently to the toilet.
Observations: Low-grade fevers noted by nursing staff; requiring 1L oxygen.
• Cardiovascular: Mechanical-sounding systolic murmur loudest in the tricuspid area, louder on inspiration; query tricuspid regurgitation.
• Respiratory: Chest clear to auscultation.
• Abdomen: Soft and non-tender.
• Neurological: Able to touch chin to chest; neck slightly stiff. No features strongly suggestive of meningism.
• Other: No peripheral oedema or rash. Chest X-ray showed cardiomegaly.

Investigations:
• Rhinovirus nasopharyngeal swab: Positive
• Blood cultures: Normal
• Urea and electrolytes: Normal
• LFTs: ALT 159, AST 57
• CRP: 23
• Coagulation screen: Normal
• White cell count: 9.6
• Neutrophils: 7.36
• Chest X-ray: Cardiomegaly, no gross lung lesion, apical film clear

Impression:
Rhinovirus infection on a background of cyanotic congenital heart disease with oxygen requirement and mild liver injury.
Differential Diagnoses: Meningitis less likely.

Management Plan:
1. Supportive management for rhinovirus infection.
2. Add blood-borne virus screen including EBV, CMV and HIV.
3. Monitor oxygen requirement and repeat observations.
4. Encourage mobilisation and trial off oxygen.
5. Discharge home once no longer requiring oxygen and clinically improving.
6. Discuss findings, including cardiomegaly on chest X-ray and examination murmur, with the patient; he reports known Ebstein’s anomaly under Royal Brompton follow-up.

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Notes Sat 04 April 2026 16:07

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Notes Sat 04 April 2026 16:10

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Refined clerking Sat 04 April 2026 20:46

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Refined clerking Sat 04 April 2026 20:47

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Refined clerking Thu 02 April 2026 13:04

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Refined clerking Sat 04 April 2026 21:33

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