Physician's Assistant

Patient Details

Refined clerking (55 days ago 10:22)

Refined clerking Tue 10 February 2026 10:22

Last Modified: 55 days ago

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Content:

Medical ST5 Miller Clerking
10/02/26 09:30

Presenting Complaint:
Sudden onset shortness of breath

History of Presenting Complaint:
This 72-year-old lady was recently discharged from McCullum Ward on 9th February 2026 following admission on 6th February with shortness of breath and wheeze. On that admission, saturations were 86% on arrival to ED. She was started on her rescue pack and received hydrocortisone, then admitted under the medical team. She was discharged home yesterday evening (9th February). No discharge summary available.

She felt well after discharge but woke during the night with sudden onset shortness of breath. No chest pain. No cough. No fever. Uses inhalers and nebulizers regularly at home. Feels persistently wheezy despite treatment.

Received recent course of amoxicillin from GP on 6th February for exacerbation of COPD. Has been attempting to wean prednisolone from 6 tablets (30mg) down to 3 tablets (15mg) prior to recent admission.

Past Medical History:
• COPD with frequent exacerbations
• Type 2 diabetes mellitus with retinopathy
• Myocardial infarction (2008)
• Heart failure - echo April 2022: mild reduction in LV systolic function, no significant valve abnormality
• Osteoporosis - on zoledronic acid infusions since 2019
• Osteopenia
• Depression
• Previously housebound, now mobile on mobility scooter

Drug History:
• Sertraline 100mg PO OD
• Metformin 1g MR PO OD
• Prednisolone 15mg PO OD (recently weaned from 30mg)
• Doxycycline 100mg PO three times weekly (Monday, Wednesday, Friday)
• Theical D3 1 tablet PO OD
• Salbutamol inhaler PRN
• Salbutamol nebulizers QDS
• Atorvastatin 80mg PO OM
• Doxycycline rescue pack
• Sodium chloride inhalation solution nebulizer BD
• Trimbow 87/5/9 microgram inhaler 2 puffs BD
• Zoledronic acid infusions (started 2019)
• Esomeprazole 20mg PO OD
• Beclomethasone nasal spray 2 sprays each nostril BD
• Carbocisteine 750mg PO TDS
• Ezetimibe 10mg PO OD
• Aspirin 75mg PO OD
• Ramipril 2.5mg PO OD

Allergy History:
NKDA

Social History:
Lives alone. Has home help once weekly on Wednesdays for housework and bed changes. Normally manages independently but finds housework difficult when unwell. Uses mobility scooter to travel to local shops and beach. Has not been out for few weeks due to poor weather. Does online shopping for groceries when not going out herself.
Ex-smoker - quit 10 years ago. Smoked from age 22 to 62 (approximately 40 pack years, smoking 1 pack daily).
Does not drink alcohol.

On Examination:
Alert, conversing in full sentences but visibly breathless.
Observations: Temperature 37.3°C (afebrile since presentation), HR 105, RR 19, BP 135/98, O2 saturations 94% on 2L oxygen (92% on room air when assessed by respiratory nurse previously, dropping to 87% when oxygen removed during consultation)
• Cardiovascular: No peripheral oedema. Bruising noted on legs.
• Respiratory: Bilateral wheeze on auscultation. Hyperexpanded chest.
• Abdomen: Soft, mild generalized tenderness, no masses, no organomegaly
• Other: Bruising on lower limbs, no rashes

Investigations:
• VBG on admission: pH 7.27, lactate 5.4, base excess -5.3, pCO2 6.3
• ABG (subsequent): pH 7.38, pCO2 5.7, base excess -0.4, lactate improved to 1.7
• Sodium 142
• Potassium 4.7
• Creatinine 51 (baseline)
• Urea 4.8
• CRP 2
• Hb 113 (normocytic anemia)
• WCC 20.4
• Neutrophils 10.52
• LFTs: AST normal
• Respiratory culture awaited
• CXR (current): Clear lung bases, possibly some hazy left basal opacification , hyperexpanded film
• CXR (6th February): Clear lung fields
• Echo (April 2022): Poor quality echo with apical views only, overall mild reduction in LV systolic function, no significant valve abnormality

Impression:
Acute exacerbation of COPD with rapid relapse following recent discharge. Initial presentation with type 2 respiratory failure (acidotic VBG) now compensated. Likely precipitated by too rapid steroid wean. No clear infective component (CRP 2, clear CXR, no fever, no productive cough).

Secondary issues: Oxygen-dependent requiring 1-2L to maintain target saturations 88-92%. Normocytic anemia. Type 2 diabetes mellitus. Known heart failure.

Management Plan:
1. Increase prednisolone to 30mg PO OD (from current 15mg)
2. Continue regular salbutamol nebulizers QDS
3. Continue Trimbow inhaler 2 puffs BD
4. Continue carbocisteine 750mg TDS
5. Request troponin to exclude cardiac cause
6. Request magnesium and consider IV magnesium sulphate for bronchodilation
7. Maintain oxygen therapy targeting saturations 88-92%
8. Admit to Respiratory Ward for ongoing monitoring and treatment
9. Consider NIV if deterioration occurs
10. No antibiotics indicated currently (no evidence of infection)
11. Facilitate window bed to improve patient comfort
12. Escalation plan discussed: Patient willing for ward-based treatment and NIV if required. Not for CPR or ITU escalation given severity of underlying lung disease and high risk of significant disability post-arrest.
13. Ensure family contact - daughter to be informed of admission

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Summary:

Investigations:

Tasks

Feedback

• Consider reviewing discharge summary from previous admission (9th February) before seeing patient - this would have provided context about steroid dosing and management plan that led to rapid relapse
• Excellent rapport building and social history taking, but consultation became fragmented with multiple off-topic conversations that delayed care
• When patient's oxygen saturations dropped to 87% off oxygen, this was an important clinical finding that should have prompted immediate management discussion rather than continuing with extended examination
• Safety-netting could be strengthened - patient needs clear written advice about when to seek help, red flags for deterioration, and specific instructions about her oxygen use at home
• Good approach to resuscitation discussion, appropriately exploring quality of life concerns and explaining risks clearly
• Consider earlier structured handover to ward team - prolonged clerking in acute area may have delayed definitive care (steroids, magnesium)
• Missed opportunity to explore medication concordance - patient on complex regimen with multiple inhalers, important to check technique and understanding
• Examination findings documented but could be more systematic - no formal respiratory examination scoring (e.g., peak flow if able, or assessment of work of breathing using accessory muscles)
• Good identification of social vulnerability (lives alone, limited support) but no documented referral to social services or consideration of increased package of care given recurrent admissions