Physician's Assistant

Refined clerking (88 days ago 02:50)

Refined clerking Thu 08 January 2026 02:50

Last Modified: 88 days ago

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Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Acute deterioration

History of Presenting Complaint:
This is a retrospective note following acute deterioration of an inpatient. The patient became acutely agitated and confused this evening with significant breathing difficulties requiring large amounts of oxygen. Working diagnosis is aspiration pneumonia secondary to Parkinsonian crisis, which occurred due to missing medication caused by gastric compression from his newly diagnosed lymphoma. Approximately 20 minutes after family review, patient's oxygen saturations dropped to 75% on 15 litres non-rebreather mask with GCS falling to 6, prompting a peri-arrest call.

Past Medical History:
• Parkinson's disease
• Upper abdominal lymphoma (newly diagnosed)

Drug History:
• Rotigotine patch (for Parkinsonian crisis - recently missing due to gastric compression)

Allergy History:
Unknown

Social History:
Family includes 3 sons, wife and daughter-in-law who are medically knowledgeable and involved in care decisions.

On Examination:
General Appearance: Acutely unwell, agitated, confused with breathing difficulties
Observations: O2 sats 75% on 15L non-rebreather, GCS 6
• Respiratory: Significant respiratory distress requiring high-flow oxygen
• Neurological: GCS 6, features consistent with Parkinsonian crisis

Investigations:
• CT scan: 14cm upper quadrant mass consistent with lymphoma with central necrosis, features abutting vasculature and other structures with possible invasion, gastric distortion, no other lymphadenopathy

Impression:
Aspiration pneumonia secondary to Parkinsonian crisis
Secondary to newly diagnosed upper abdominal lymphoma (14cm mass)
Acute respiratory failure

Management Plan:
1. ITU review completed - intubation and ventilation deemed not beneficial due to significant aspiration event and poor prognosis
2. Transfer to Midgley Ward (respiratory ward)
3. Establish BiPAP ventilation (preferred over Airvo due to high CO2)
4. Site Ryles tube following transfer
5. Follow-up chest X-ray post-Ryles tube insertion to confirm correct placement
6. Continue rotigotine patch for Parkinsonian crisis
7. Family updated and understand current situation and poor prognosis
8. Escalation plan: Not suitable for intubation/ventilation as per ITU consultant review - would be unlikely to wean and would result in profound disability precluding lymphoma treatment

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Email (88 days ago 09:00)

Email Thu 08 January 2026 09:00

Last Modified: 88 days ago

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Refined ultra rapid review (88 days ago 02:51)

Refined ultra rapid review Thu 08 January 2026 02:51

Last Modified: 88 days ago

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Medical ST5 Miller Review

Reason:
Acute deterioration with agitation, confusion and breathing difficulties in patient with newly diagnosed abdominal mass

History:
Patient became acutely agitated and confused this evening with difficulty breathing requiring large amounts of oxygen. Working diagnosis of aspiration secondary to Parkinsonian crisis, likely precipitated by missing medication due to gastric compression from lymphoma.

Examination:
Sats 75% on 15 litres non-rebreather mask, GCS 6, peri-arrest state

Impression:
14cm upper quadrant mass consistent with lymphoma with central necrosis and possible vascular invasion. Significant aspiration event, possibly secondary to Parkinsonian crisis and gastric distortion from intra-abdominal malignancy. ITU consultant assessment: intubation and ventilation not beneficial due to poor prognosis and unlikely ventilator weaning.

Plan:
1. Establish BiPAP ventilation
2. Transfer to Midglee ward (respiratory ward)
3. Site Ryles tube
4. Follow-up chest X-ray post Ryles tube insertion
5. Allow time for rotigotine patch to work for Parkinsonian crisis
6. Family updated and understand current situation

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Rapidreview (88 days ago 02:52)

Rapidreview Thu 08 January 2026 02:52

Last Modified: 88 days ago

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EMERGENCY WARD CONSULTATION - ACUTE DETERIORATION

Written in retrospect

FAMILY DISCUSSION:
Updated family (3 sons, wife and daughter-in-law) in the family room. Explained findings of CT scan demonstrating a 14cm upper quadrant mass consistent with possible lymphoma with areas of central necrosis and features abutting vasculature and other structures with possibility of invasion.

Explained patient had become more unwell this evening - acutely agitated and confused with difficulty breathing requiring large amounts of oxygen. Working diagnosis: aspiration secondary to Parkinsonian crisis secondary to missing medication due to gastric compression from lymphoma.

Family were accepting and understanding of the situation. As they have medical background, I was able to answer their questions appropriately.

ACUTE DETERIORATION:
Approximately 20 minutes after family review, patient review showed:
- Oxygen saturations 75% on 15L non-rebreathable mask
- GCS 6
- Peri-arrest state identified

Peri-arrest call activated. Arrest team and ITU attended.

ITU CONSULTANT REVIEW:
Long discussion with ITU consultant regarding patient's condition. ITU assessment:
- Significant aspiration event today, likely secondary to Parkinsonian crisis and gastric distortion from lymphoma (or other intra-abdominal malignancy)
- No other lymphadenopathy noted on CT scan
- Intubation and ventilation deemed non-beneficial due to severity of aspiration
- Concerns patient would be unable to wean from ventilator
- If successful weaning occurred, patient would likely be profoundly disabled and not candidate for lymphoma treatment

PLAN:
1. Insert Ryles tube
2. Transfer to respiratory ward (Midglee Ward)
3. Commence BiPAP (ITU recommended Airvo, but BiPAP preferred due to high CO2 concerns)
4. Allow time for rotigotine patch to work for Parkinsonian crisis
5. Follow-up chest X-ray post Ryles tube insertion to confirm correct placement

Family updated on all developments. They understand the situation, have no further questions, and are aware of how unwell the patient currently is.

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Refined clerking Thu 08 January 2026 02:50

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Email Thu 08 January 2026 09:00

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Refined ultra rapid review Thu 08 January 2026 02:51

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Rapidreview Thu 08 January 2026 02:52

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