Physician's Assistant

Patient Details

Refined clerking (190 days ago 05:17)

Refined clerking Sun 28 September 2025 05:17

Last Modified: 190 days ago

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Medical ST5 Miller Clerking

Presenting Complaint:
Shortness of breath

History of Presenting Complaint:
This 68-year-old gentleman was rehabilitating at Brixham Hospital following multiple fractures from a fall when he developed sudden onset shortness of breath. He has been experiencing a non-productive cough for 3 days prior to the onset of breathlessness. He denied chest pain, fever, or obvious aspiration event.

He was treated for pulmonary oedema with furosemide and GTN, showing good clinical response. On arrival he required 10L oxygen but has since been weaned to 1L. He reports feeling much better following treatment.

He reports loose urgent stools and urinary incontinence following recent fall.

Past Medical History:
• Left breast grade 2 invasive ductal carcinoma - left mastectomy and axillary node clearance July 2025
• Concurrent bladder cancer
• Progressive bony metastatic disease with lesion in left fifth rib posteriorly
• Recent admission August 2025 following fall down 13 steps sustaining:
  - Right scapular blade fracture
  - C5 fracture of left lamina
  - L4 fracture of right transverse process
• Conservative management of fractures with ongoing analgesia
• Lymphoedema affecting left arm post-LN clearance
• CCF - no recent echocardiogram or BNP
• AF
• Erectile dysfunction

Drug History:
• Atorvastatin 20mg PO OD
• Mometasone 0.1% topical BD
• Paracetamol 1g PO QDS PRN
• Tamsulosin MR 400mcg PO OD
• Bimatoprost 300mcg/Timolol 5mg per ml 1 drop OM
• Dermol 500 PRN
• Bumetanide 1mg PO OM
• Rivaroxaban 20mg PO OD
• Tadalafil 5-10mg PRN
• Laxido 1-2 sachets BD

Allergy History:
• Penicillin
• Pregabalin
• Amitriptyline
• Codeine

Social History:
Lives with partner in own house. Previously independent with no mobility aids. Retired roofer. Non-smoker, social drinker.

On Examination:
General Appearance: Alert, well-appearing gentleman, comfortable at rest
Observations: HR 93, BP 157/81, Temp 36.6°C, RR 22, O2 sats 97% on 1L oxygen
• Cardiovascular: Heart sounds normal, no murmurs audible, very mild ankle oedema bilaterally
• Respiratory: Bilateral crepitations in bases L > R.
• Neurological: Left arm weakness (longstanding) secondary to lymphoedema post-mastectomy
• Other: Chronic venous changes in legs, no signs of infection, lymphoedema dressing to left arm

Investigations:
• Troponin: 62 (from 48)
• Venous blood gas: pH 7.32, CO2 7.2
• Arterial blood gas: CO2 5.1, O2 sats 83%
• Creatinine: 78 (baseline 66)
• Potassium: 5.4
• INR: 1.9
• ALP: 219 (chronically raised since August 2025)
• CRP: 5
• Urea: 11.7 (from 6.5)
• Hb: 108 (normocytic)
• Platelets: 135 with neutrophilia
• Chest X-ray: Poorly inspired portable film, increased bronchovascular markings throughout, no pleural effusions
• ECG: Atrial fibrillation with rate 86 bpm

Impression:
Pulmonary oedema - improved with treatment
No clinical evidence of infection
Raised troponins without chest pain ? cardiac event as a cause for pulmonary oedema
Laxatives - likely overflow diarrhoea

Management Plan:
1. IV Furosemide
2. Add NT-proBNP to blood tests 
3. Wean oxygen as able
4. Daily UE when on IV diuresis
5. Stop antibiotics
6. Increase laxatives
7. AMU
8. Aspirin and clopidogrel load and regular#
9. Return to community hospital for ongoing rehabilitation as soon as medically stable
10. Echocardiogram

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Refined clerking Sun 28 September 2025 05:17

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