Physician's Assistant

Patient Details

Refined clerking (151 days ago 17:24)

Refined clerking Thu 06 November 2025 17:24

Last Modified: 151 days ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Haemoptysis

History of Presenting Complaint:
Mr Clay is an 80-year-old gentleman who travelled by coach from Leicester to Devon on Wednesday for a holiday. On Tuesday night before departure, he had been coughing and the family debated whether to proceed with the trip. He felt better Wednesday morning so they continued with their plans.

Since arrival, he has been increasingly lethargic, tired and short of breath. He has experienced low-grade pyrexia with temperatures ranging from 37.0-37.9°C, recorded by his wife.

Single episode of haemoptysis associated with a cough

Past Medical History:
• Type 2 diabetes mellitus - on insulin
• Ischaemic Heart Disease - CABG x2 with mitral valve repair 2009
• Atrial fibrillation - on warfarin (target INR 2-3, last INR 3.2)
• Dementia - mild, on donepezil
• Benign prostatic hyperplasia
• Previous diverticulitis
• Previous pneumonia with haemoptysis
• Ex-smoker - 20/day for approximately 40 years, stopped 2008

Drug History:
• Ramipril 5mg PO evening
• Amlodipine 10mg PO evening
• Atorvastatin 80mg PO nocte
• Bisoprolol 2.5mg PO morning
• Donepezil 10mg PO evening
• Tamsulosin 400mcg PO morning
• Thiamine 100mg PO evening
• Finasteride 5mg PO morning
• Furosemide 40mg PO morning and lunchtime
• Lansoprazole 15mg PO morning
• Insulin (basal-bolus regimen): Insulatard 20 units breakfast, 10 units evening; Actrapid 4 units with meals as required
• Metformin (dose reduced recently due to eGFR)
• Warfarin 3mg OD, 4mg Sundays (target INR 2-3)

Allergy History:
• NKDA

Social History:
Lives with wife who is very supportive and monitors his observations and medications closely. Daughter-in-law is a pharmacist who oversees medication management. Independent with activities of daily living around the house. Former legal practitioner specialising in probate. Ex-smoker - ceased 2008 following heart attack. Minimal alcohol consumption, stopped completely since commencing donepezil.

On Examination:
General Appearance: Alert but pale and diaphoretic
Observations: On 7L oxygen
• Cardiovascular: Heart sounds I and II present, pansystolic murmur, pitting oedema to knees bilaterally
• Respiratory: Bilateral fine crepitations to mid-zones, upper airway sounds throughout the anterior chest
• Abdomen: Soft, non-tender

Investigations:
• Hb 87
• Neutrophils 7.44 with monocytopenia
• Chest X-ray: Patchy airspace consolidation within right and left middle zones consistent with widespread infection, no pleural effusion
• Venous blood gas: pH 7.41, base excess -7.1 (metabolic acidosis with respiratory compensation, likely secondary to hyperchloraemia)

Impression:
CAP

Management Plan:
1. IV antibiotics - CURB65 [_]
2. Encourage expectoration
3. Blood tests including renal function, LFTs, inflammatory markers - review meds with results
4. Sputum MC&S and Blood cultures
5. Viral quad swab
6. Haematinics
7. Chest physiotherapy 
8. Carbocisteine and nebulisers
9. IO monitoring
10. Continue warfarin with INR monitoring
11. Respiratory bed

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Rapidreview (151 days ago 21:23)

Rapidreview Thu 06 November 2025 21:23

Last Modified: 151 days ago

MRN:

Content:

Further review at 20:30.

On arrival:
- Pulse rate: 88 bpm
- Oxygen saturation: 92% on 15 litres non-rebreather oxygen
- Respiratory rate: 29/min
- Blood pressure: 130/55 mmHg

O/E Chest: Bilateral crepitations to mid-zones. Bilateral lower limb oedema to knees.

Investigations:
Reviewed blood tests from earlier which were not originally available. CRP significantly raised with AKI (most likely), although no baseline available for comparison.

Discussion:
Explained to patient and wife how unwell he is with this significant oxygen requirement and evidence of bilateral infection on chest X-ray. There may be an element of fluid overload given his cardiac background leading to worsening oxygenation, so suggested trial of furosemide to see if this improves things.

He is currently on 15 litres oxygen and uncertain how long he will be able to maintain this level. He might benefit from intensive care support and this was discussed.

He has strong Christian faith and does not wish to be for CPR, which is entirely reasonable and what I would suggest clinically. However, despite his comorbidities of diabetes, ischaemic heart disease, CKD, prostatic hypertrophy and mild Alzheimer's dementia, he was well enough to travel by coach for a planned holiday. His functional baseline is therefore not too poor.

Considered whether he might benefit from intensive care for single organ support (increased oxygen demand) with clearly reversible cause such as pneumonia, and he would be agreeable to this. DNAR form completed to that effect.

Plan:
1. Catheterise
2. IV furosemide
3. Repeat ECG
4. ITU review
5. Arterial blood gas

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Summary:

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