Physician's Assistant

Patient Details

Refined ultra rapid review (55 days ago 09:25)

Refined ultra rapid review Tue 10 February 2026 09:25

Last Modified: 55 days ago

MRN:

Content:

Medical ST5 Miller Review

Reason:
Highlighted by night team as unwell with hypotension and element of diagnostic uncertainty.

History:
Mrs Lamble is an elderly widow who lives alone. Her husband died 13 years ago and she has limited mobility. She lost her daughter to breast cancer; two grandchildren live in the Midlands with whom she maintains telephone contact. She has a brother-in-law who is aware of her admission.

She fell from the side of the bed on Sunday night whilst preparing for bed. Activated her alarm and was brought in by ambulance.

Since admission has been investigated for shortness of breath and hypotension. Known aortic stenosis. Has had recent echo (timing unclear). No significant cough, minimal sputum production, no haemoptysis. Non-productive cough described as tickle. No dysuria or urinary symptoms.

PMHx: Aortic stenosis, rheumatoid arthritis, bilateral leg ulcers currently being treated with compression bandaging (left leg has one week remaining, right leg almost healed).

Social: Lives independently but limited by mobility. Social network diminishing. Brother-in-law acts as main contact.

Examination:
BP 86/51 mmHg (hypotensive)
Chest auscultation: crackles heard bilaterally
Legs: bilateral compression bandaging in situ for venous ulcers, small ulcers present but healing
Urinary catheter in situ (inserted during admission) - draining concentrated urine in small amounts
Patient appears frail

Investigations:
VBG: pH 7.43, Hb 97g/L, Creatinine 107 µmol/L (baseline 70), K+ 5.5 mmol/L, Na+ 140 mmol/L
Bloods: ALP 175 U/L, Bilirubin 27 µmol/L (previously 11), CRP 111 mg/L, Urea 9.7 mmol/L, INR 3.2, Hb 104 g/L, MCV 79.4 fL
Haematinics: Pattern consistent with iron deficiency anaemia
CXR: Fluid in fissure and right-sided pleural effusion with associated consolidation. Left base relatively clear but some increased bronchovascular markings bilaterally
COVID quad swab: Negative
Blood cultures: Negative so far
Oliguria noted

Impression:
Hypotension with raised inflammatory markers more consistent with infection than fluid overload as cause of shortness of breath. Hospital-acquired pneumonia most likely. Diagnostic uncertainty regarding contribution of known aortic stenosis and possible rheumatoid changes to chest findings. Acute kidney injury (Cr 107 from baseline 70). Iron deficiency anaemia. Healing bilateral leg ulcers.

Plan:
1. Continue Cotrimoxazole (not Meropenem as previously documented)
2. Slow IV fluids aiming for MAP >65 mmHg in context of sepsis
3. Manage as community-acquired pneumonia
4. Swab bilateral leg wounds to guide whether these may be source of infection
5. Input/output monitoring given oliguria
6. Recheck potassium today (currently 5.5 mmol/L)
7. Suspend Adalimumab for now
8. Transfer to Acute Medical Unit for ongoing care
9. Iron studies and consideration of iron supplementation for anaemia

Field Clipboard (for EPR paste)

Builds copy buttons from the headings currently in the note, and also lets you copy the entire note.

Summary:

Investigations:

Tasks

Feedback

• Consider documenting the timing of the recent echocardiogram more specifically - this is important given the known aortic stenosis and current hypotension, as it would help differentiate cardiac vs septic causes
• Missed opportunity to explore red flag symptoms more systematically - no documentation of chest pain assessment, which is crucial in a patient with aortic stenosis and pleural effusion
• Social situation well explored, but consider formalizing safeguarding assessment given patient lives alone with limited mobility and unclear if she can safely return home
• Communication could be improved - patient appears somewhat confused about medication changes (Cotrimoxazole vs Meropenem) and the explanation of diagnostic uncertainty was limited
• Excellent empathy shown when dealing with patient's phone connectivity issues and personal items - good holistic care
• Consider earlier involvement of geriatrics given frailty, falls, and complex social needs
• Safety-netting could be strengthened - no clear discussion documented about deterioration signs or escalation plan explained to patient