Physician's Assistant

Refined clerking (45 days ago 11:44)

Refined clerking Fri 20 February 2026 11:44

Last Modified: 45 days ago

MRN:

Content:

{
  "mrn": "548198",
  "patient_name": "Jeffrey Tompkins",
  "content": "Medical ST5 Miller Clerking\n\nPresenting Complaint:\nChest pain / palpitations\n\nHistory of Presenting Complaint:\nJeffrey Tompkins is a 93-year-old gentleman with a significant cardiac history who presented to the Emergency Department in the early hours of the morning with recurrent chest pain and palpitations.\n\nHe has a background of exertional chest discomfort for approximately one year, which he reports is consistent with his known ischaemic heart disease. He describes becoming breathless and experiencing chest discomfort after walking only 10–20 yards, which limits his daily activities considerably.\n\nYesterday morning (25/02/26), he woke between 08:30 and 09:30 and developed central chest pain with a squeezing character, radiating to the back, associated with sweating and clamminess. This episode lasted approximately one hour before subsiding spontaneously. He was pain-free for the remainder of the morning. Later that afternoon, at approximately 18:30, he went out for coffee and developed a further episode of chest pain lasting several hours. On returning home, he was unable to lie flat due to cough. At approximately 01:00 this morning, his chest pain returned and, at his wife's persuasion, he called for help and attended hospital.\n\nHe also reports a one-to-two-day history of episodic visual disturbance, occurring three times during this admission. He describes a sudden onset, with a sensation of something in his vision accompanied by a loud noise, with complete resolution shortly afterwards. These episodes are temporally associated with his heart going into a fast rhythm, suggesting haemodynamic compromise during episodes of supraventricular tachycardia (SVT). This symptom had not been present prior to this presentation.\n\nSeparately, he reports a two-to-three-month history of left-sided neck and shoulder pain radiating up the back following a fall at home, in which he was struck by a door and knocked off his feet. He did not seek medical attention at the time. This pain has persisted since.\n\nHe was reviewed by the ACS nurse in the Emergency Department. He is well known to cardiology.\n\nRegarding medications: isosorbide mononitrate had previously been stopped but was restarted by his GP one to two weeks prior to this presentation. He has been taking aspirin daily as prescribed.\n\nPast Medical History:\n• Ischaemic heart disease — primary percutaneous coronary intervention (PCI) to OM1 with two stents, July 2020; previous elective PCI to the right coronary artery (RCA) and distal/mid LAD with two stents for CCS Class 3 angina, June 2020; bystander distal LAD and distal circumflex disease managed medically\n• Cholecystectomy — 1990\n• Fractured neck of femur — 2019, managed with dynamic hip screw (DHS); walks slowly with aid of a stick\n• Small bowel obstruction — 2021\n• Benign paroxysmal positional vertigo (BPPV)\n• Hypertension\n• Chronic kidney disease — Stage 3\n• Colonic diverticulosis\n• Primary open-angle glaucoma\n• Bilateral hip replacements\n• Background pulmonary fibrosis (noted on CT July 2023, progressed compared with CT 2019)\n\nDrug History:\n• Alendronic acid 70mg PO once weekly\n• Calcichew D3 1 tablet PO OD\n• Furosemide 20mg PO OD\n• Atorvastatin 40mg PO OD\n• Aspirin 75mg PO OD\n• Omeprazole 20mg PO OD\n• Latanoprost 50mcg/ml eye drops — both eyes OD\n• Lisinopril 10mg PO OD\n• Isosorbide mononitrate — recently restarted by GP (see below)\n\nRecently Stopped Medications:\n• Isosorbide mononitrate — stopped several weeks ago, restarted by GP approximately one to two weeks prior to this admission\n\nAllergy History:\n• NKDA\n\nSocial History:\nLiving situation: Lives with his wife in a bungalow.\nMobility: Walks with a stick, though able to manage short distances without it. Functional range limited to approximately 10–20 yards before becoming breathless.\nOccupation: Retired chauffeur, ceased working in 2019. The family business was established by his father in 1924.\nSmoking: Ex-smoker — smoked approximately 20 cigarettes per day during his twenties; ceased following a chest problem. Estimated light pack-year history.\nAlcohol: Previous heavy whisky drinker; currently does not drink.\nFunctional Status: Manages at home with his wife. Active in the garden. Wears glasses for visual impairment secondary to glaucoma.\n\nOn Examination:\nGeneral Appearance: Alert and conversant. Cooperative with examination.\nObservations: HR fluctuating between 94–95 bpm in sinus rhythm and episodes of SVT at approximately 160 bpm. BP 102/77 mmHg. RR 23. O2 saturations 97% on air.\n\n• Cardiovascular: JVP not raised. Heart sounds noted; palpitations confirmed on examination. During the consultation, the patient experienced further episodes of visual disturbance correlating with SVT on monitoring.\n• Respiratory: Lungs auscultated — stiff lung fields consistent with age and background fibrosis. No acute findings to suggest pulmonary oedema on examination, though left basal haziness noted on imaging (see below).\n• Abdomen: Examined — no specific findings documented.\n• Other: Bilateral hip replacements noted. Left neck and shoulder tenderness consistent with history of fall two to three months ago.\n\nInvestigations:\n• Haemoglobin: 113 (previously 115 and 109 in June and February respectively)\n• Troponin T: 397 at 06:23 and 207 at 02:48\n• Venous blood gas: Normal\n• Full blood count: Normal\n• Urea: 16.6\n• Creatinine: 156 (previously 128 in November 2025) — consistent with AKI Stage 1\n• ALT: 50 (previously 9 in June 2025)\n• AST: 53\n• CRP: <1\n• Liver function tests: Otherwise normal\n• CRP (repeat): Awaited\n• Coagulation screen: Awaited\n• Chest X-ray (26/02/26): Clear lung fields with mild left basal haziness at the costophrenic angle; increased bronchovascular markings bilaterally compared with previous X-ray from 2023, which showed left lower zone atelectasis — overall stable appearances\n• CT Thorax, Abdomen and Pelvis (July 2023, indication: trauma): Background pulmonary fibrosis progressed compared with CT 2019; post-cholecystectomy changes; liver cyst; heavy aortic calcification; atrophic right kidney; faecal loading in rectum; uncomplicated colonic diverticulosis; bilateral hip replacements; osteopenia; degenerative spinal changes; no rib fractures\n\nImpression:\nNSTEMI — in the context of rising troponin (peak 397), exertional chest pain, and diaphoresis, on a background of significant ischaemic heart disease with prior PCI.\nSVT — with episodes of visual disturbance likely secondary to haemodynamic compromise during tachycardic episodes.\nAKI Stage 1 — creatinine 156, up from baseline of 128 in November 2025.\nMild transaminitis — ALT 50 (previously 9 in June 2025), aetiology to be determined.\n\nDifferential Diagnoses: Atrial fibrillation (to be confirmed on ECG review); demand ischaemia secondary to tachyarrhythmia.\n\nManagement Plan:\n1. Monitoring: CCU bed with continuous cardiac monitoring. Long line to be inserted for amiodarone infusion.\n2. Medications:\n   a. Amiodarone infusion — commenced for rhythm control\n   b. Fondaparinux 2.5mg SC OD — for NSTEMI management and VTE prophylaxis\n   c. Apixaban 2.5mg PO BD — as recommended by cardiology (Dr Hayder) for dual indication: anticoagulation for atrial fibrillation and NSTEMI medical management\n   d. Clopidogrel 300mg PO loading dose, then 75mg PO OD — as per cardiology recommendation\n   e. Aspirin 75mg PO OD — to be ceased in favour of clopidogrel as per cardiology guidance\n   f. Isosorbide mononitrate — restarted; to continue to ensure the patient remains pain-free\n3. Investigations: Repeat coagulation screen and CRP when available. Ongoing monitoring of renal function and troponin trend. Review ECG for atrial fibrillation.\n4. Referral: Cardiology review — discussion regarding suitability for repeat coronary angiography given NSTEMI in context of prior stenting.\n5. Escalation plan: Discussion held with the patient regarding resuscitation. He is for CPR and attempted cardioversion in the context of a clearly reversible arrhythmic cause. If prolonged resuscitation without an identified reversible cause, prompt cessation is appropriate given his advanced age (93 years). He has capacity and expressed agreement with this approach. DNACPR form to be completed and filed. His quality of life was noted to be reasonable — he remains active at home, particularly in the garden.\n6. Ward: Cardiology CCU bed.",
  "summary": "Jeffrey Tompkins is a 93-year-old gentleman with significant ischaemic heart disease (prior PCI with stenting) presenting with recurrent central chest pain, diaphoresis, and palpitations with associated transient visual disturbance. Elevated troponin T (peak 397) and clinical picture are consistent with a diagnosis of NSTEMI with concurrent SVT/possible atrial fibrillation.",
  "investigations": "Haemoglobin 26/02/26: 113 (previously 115 and 109 in June and February respectively)\nTroponin T 26/02/26 02:48: 207\nTroponin T 26/02/26 06:23: 397\nVenous blood gas 26/02/26: Normal\nFull blood count 26/02/26: Normal\nUrea 26/02/26: 16.6\nCreatinine 26/02/26: 156 (previously 128, November 2025) — AKI Stage 1\nALT 26/02/26: 50 (previously 9, June 2025)\nAST 26/02/26: 53\nCRP 26/02/26: <1\nCoagulation screen: Awaited\nCRP repeat: Awaited\nChest X-ray 26/02/26: Mild left basal haziness at costophrenic angle; increased bronchovascular markings bilaterally; stable compared with 2023 (which showed left lower zone atelectasis)\nCT Thorax Abdomen and Pelvis July 2023: Background pulmonary fibrosis (progressed vs 2019); post-cholecystectomy; liver cyst; heavy aortic calcification; atrophic right kidney; faecal loading in rectum; uncomplicated colonic diverticulosis; bilateral hip replacements; osteopenia; degenerative spinal changes; no rib fractures",
  "tasks": [
    {
      "item": "Arrange CCU bed with continuous cardiac monitoring",
      "time_frame": "2026-02-20T12:00:00",
      "request": "Please arrange a CCU bed with continuous cardiac monitoring for Jeffrey Tompkins (MRN: 548198), a 93-year-old gentleman admitted with NSTEMI (peak troponin T 397) and SVT (HR up to 160 bpm). He is currently on an amiodarone infusion and requires a long line for administration. Ongoing monitoring of heart rhythm, blood pressure, and oxygen saturations is essential."
    },
    {
      "item": "Insert long line for amiodarone infusion",
      "time_frame": "2026-02-20T12:00:00",
      "request": "Please insert a long line (PICC or central venous access) for Jeffrey Tompkins (MRN: 548198) to facilitate administration of amiodarone infusion. Peripheral administration is not appropriate for prolonged amiodarone infusion due to phlebitis risk. Patient is a 93-year-old on CCU with NSTEMI and SVT requiring rhythm control."
    },
    {
      "item": "Prescribe amiodarone infusion",
      "time_frame": "2026-02-20T12:00:00",
      "request": "Please prescribe amiodarone infusion for Jeffrey Tompkins (MRN: 548198), a 93-year-old with confirmed SVT and NSTEMI. Standard loading and maintenance infusion protocol to run for approximately 12 hours as per NSTEMI and arrhythmia management. Long line to be arranged prior to commencement."
    },
    {
      "item": "Prescribe fondaparinux 2.5mg SC OD",
      "time_frame": "2026-02-20T12:00:00",
      "request": "Please prescribe fondaparinux 2.5mg SC OD for Jeffrey Tompkins (MRN: 548198) for NSTEMI management and VTE prophylaxis. Note CKD Stage 3 (creatinine 156, AKI Stage 1 on background of 128). Renal function monitoring required."
    },
    {
      "item": "Prescribe apixaban 2.5mg PO BD",
      "time_frame": "2026-02-20T12:00:00",
      "request": "Please prescribe apixaban 2.5mg PO BD for Jeffrey Tompkins (MRN: 548198) as recommended by cardiology (Dr Hayder) for dual indication: anticoagulation for possible atrial fibrillation and NSTEMI medical management. Note: aspirin to be ceased; clopidogrel 300mg loading dose then 75mg OD to be commenced concurrently."
    },
    {
      "item": "Prescribe clopidogrel 300mg loading then 75mg OD — cease aspirin",
      "time_frame": "2026-02-20T12:00:00",
      "request": "Please prescribe clopidogrel 300mg PO loading dose followed by 75mg PO OD for Jeffrey Tompkins (MRN: 548198) as per cardiology recommendation (Dr Hayder). Aspirin 75mg OD should be ceased concurrently. Indication: NSTEMI management in the context of prior coronary stenting."
    },
    {
      "item": "Cardiology referral — review and consideration of repeat coronary angiography",
      "time_frame": "2026-02-20T13:00:00",
      "request": "Urgent cardiology review requested for Jeffrey Tompkins (MRN: 548198), a 93-year-old gentleman admitted with NSTEMI (peak troponin T 397) and SVT on a background of ischaemic heart disease with prior PCI (OM1, RCA, LAD stenting June/July 2020). He has been commenced on amiodarone infusion, fondaparinux, apixaban 2.5mg BD, and clopidogrel 300mg load per Dr Hayder's advice. Please review and advise on suitability for repeat coronary angiography. Currently awaiting CCU bed."
    },
    {
      "item": "Request 12-lead ECG and review for atrial fibrillation",
      "time_frame": "2026-02-20T12:00:00",
      "request": "Please perform and review a 12-lead ECG for Jeffrey Tompkins (MRN: 548198). Clinical concern for atrial fibrillation underlying his episodes of SVT (HR up to 160 bpm). ECG review will guide anticoagulation decision-making (apixaban already commenced per cardiology advice). Please document rhythm and

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Refined clerking (45 days ago 12:58)

Refined clerking Fri 20 February 2026 12:58

Last Modified: 41 days ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Chest pain

History of Presenting Complaint:
Mr Tompkins is a 93 year old gentleman with a background of ischaemic heart disease who presented with recurrent episodes of chest pain starting yesterday morning at 08:30-09:30. He describes central chest pain with a squeezing character radiating to the back, associated with feeling hot, sweaty and clammy. The episode lasted approximately 1 hour before subsiding. He remained well throughout the day and went out for coffee. At 18:30 he experienced another episode lasting a few hours. He went to bed but felt unable to lie flat due to coughing. Pain returned at 01:00 this morning, prompting his wife to call for help and persuade him to attend hospital. He had a further episode of chest pain just prior to arrival on the ward.

He reports chest pain on exertion over the past year which typically resolves after 10-15 minutes with rest. More recently he has been experiencing symptoms with minimal exertion. He is able to walk approximately 10-20 yards before becoming short of breath, describing chest discomfort rather than frank pain. He denies any calf claudication.

Over the past 2 days he has experienced episodes of complete visual loss lasting seconds, associated with hearing a bang or loud noise. Vision returns completely afterwards. He has had 3 such episodes whilst in hospital. These episodes appear to coincide with palpitations.

He sustained a fall 2-3 months ago when a door struck him in the front, causing him to fall backwards onto the floor. Since then he has experienced pain in his hands, neck and left shoulder blade which comes on when sitting upright.

Past Medical History:
• Ischaemic heart disease with coronary artery stenting July 2020 - STEMI managed with primary PCI to OM1 (2 stents)
• Previous elective PCI to RCA, distal/mid LAD (2 stents) for CCS Class 3 angina June 2020
• Bystander distal LAD and distal circumflex disease on medical management
• Cholecystectomy 1990
• Small bowel obstruction 2021
• BPPV
• Hypertension
• CKD Stage 3
• Colonic diverticulosis
• Primary open angle glaucoma
• Fractured neck of femur 2019 - managed with DHS, mobilises with stick

Drug History:
• Alendronic acid 70mg PO once weekly
• Calcichew-D3 1 tablet PO OD
• Furosemide 20mg PO OM
• Atorvastatin 40mg PO OD
• Aspirin 75mg PO OD
• Omeprazole 20mg PO OD
• Latanoprost 50 micrograms/ml eye drops, 1 drop to both eyes OD
• Lisinopril 10mg PO OD

Recently Stopped Medications:
• Isosorbide mononitrate - stopped few weeks ago, recently reordered by GP but not yet restarted

Allergy History:
Not documented

Social History:
Lives in a bungalow with his wife in Lychgate, approximately 30 miles from hospital. Previously worked as a chauffeur in the family business started by his father in 1924, retiring in 2019. Ex-smoker of approximately 20 cigarettes daily during his twenties, stopped due to chest problems. Drinks alcohol occasionally, previously drank whisky regularly. Mobilises with stick, able to walk short distances without aid. Walking distance limited to approximately 10-20 yards due to breathlessness. Maintains active lifestyle with gardening. Independent with ADLs. Manages stairs at home.

On Examination:
Alert 93 year old gentleman, currently experiencing visual disturbance and palpitations.
Observations: HR fluctuating between 94-160 (SVT episodes documented), BP 102/77, RR 23, SpO2 97% on air
• Cardiovascular: JVP not elevated. Heart sounds dual with irregular rhythm during examination. No peripheral oedema documented.
• Respiratory: Lungs described as "a little bit stiff" for age but functioning adequately. No acute respiratory distress.
• Abdomen: Soft, non-tender
• Neurological: Episodes of complete visual loss coinciding with arrhythmia, resolving spontaneously
• Musculoskeletal: Bilateral hip replacements noted. Neck and shoulder pain on movement.

Investigations:
• Hb 113 (previously 115 and 109 in February and June respectively)
• CRP awaited
• Coagulation screen awaited
• Venous blood gas normal
• Troponin T 397 (02:23) and 207 (02:48)
• Full blood count normal (05:00)
• Creatinine 156 (previously 128 November 2025) - AKI Stage 1
• Liver function tests normal apart from ALT 50 (previously 9 June 2025)
• CRP <1
• Urea 16.6
• AST 53
• Chest X-ray: Clear lung fields. Mild left basal haziness at costophrenic angle. Increased bronchovascular markings bilaterally compared with 2023. Previously noted atelectasis left lower zone - stable appearances.
• CT Thorax/Abdomen/Pelvis July 2023 (indication trauma): Background fibrosis progressed compared to 2019. Cholecystectomy noted. Liver cyst noted. Heavy aortic calcification. Atrophic right kidney. Faecal loading in rectum. Uncomplicated colonic diverticulosis. Bilateral hip replacements. Osteopenia. Degenerative spinal changes. No rib fractures.
• ECG: Atrial fibrillation documented

Impression:
NSTEMI with paroxysmal atrial fibrillation causing transient visual disturbances secondary to hypotension during arrhythmia episodes. Likely stent thrombosis or progression of native coronary artery disease given previous PCI.

Management Plan:
1. Amiodarone infusion via long line for rhythm control - admit to CCU with cardiac monitoring
2. Medical management of NSTEMI:
   - Apixaban 2.5mg PO BD for anticoagulation (dual purpose: AF and ACS)
   - Clopidogrel 300mg loading dose
   - Stop aspirin
3. Commence nitrate therapy to maintain pain-free
4. Discussed with Cardiology (Dr Hayder) - recommend medical management initially
5. Consider angiography ± PCI if indicated following stabilisation on CCU
6. Escalation plan discussed with patient: For CPR if clear reversible cause of arrhythmia given good baseline functional status and quality of life. However, if prolonged resuscitation without reversible arrhythmia cause, then prompt cessation given advanced age.
7. CCU bed arranged
8. Organise long line insertion for amiodarone infusion
9. Monitor renal function given AKI Stage 1
10. Consider CT head if visual symptoms persist despite rhythm control to exclude alternative neurological pathology

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Summary:

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Feedback

• Excellent rapport building and communication style with elderly patient - good use of humour and empathy throughout
• Thorough collateral history from triage notes and previous documentation
• Good exploration of visual symptoms and appropriate clinical reasoning linking to arrhythmia
• Fall history from 2-3 months ago could have been explored more systematically (mechanism, head injury, LOC, anticoagulation risk)
• Cardiovascular examination incomplete - should have documented peripheral pulses, specific heart sounds (any murmurs?), peripheral perfusion, capillary refill
• Respiratory examination findings too vague ("a little bit stiff") - should document specific findings: chest expansion, percussion note, breath sounds, added sounds
• No formal neurological examination documented despite significant visual symptoms - should examine visual fields, pupils, fundoscopy, cranial nerves
• Missing medication allergy status - should explicitly document NKDA or specific allergies
• Should have asked about compliance with cardiac medications and whether isosorbide mononitrate was restarted
• Functional assessment good but could have asked specifically about ADLs, stairs, washing, dressing, cooking
• Alcohol history somewhat unclear - "drink a lot" but then "whisky" - should quantify current units per week
• Resuscitation discussion excellent - clear, sensitive, appropriate for clinical context
• Should have arranged ECG interpretation and specific rhythm documentation rather than just "atrial fibrillation documented"
• Plan comprehensive but could have been more specific about amiodarone dosing regimen and duration
• Should document who performed Cardiology discussion (Dr Hayder mentioned) and what specific recommendations were given
• Missing safety-netting advice for patient/family regarding chest pain recurrence, palpitations, visual symptoms
• Could have explored patient's understanding of current admission and prognosis more explicitly

Refined clerking (45 days ago 10:59)

Refined clerking Fri 20 February 2026 10:59

Last Modified: 45 days ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Chest pain

History of Presenting Complaint:
Mr Tompkins is a 93-year-old gentleman presenting with recurrent chest pain over 48 hours. He has a background of stable angina for the past year, previously managed with isosorbide mononitrate (recently re-prescribed after brief cessation). His angina had been stable, limiting his walking distance to approximately 10-20 yards before developing chest discomfort and shortness of breath, with no claudication symptoms.

On the morning of 24/02/26 at 08:30-09:30, he developed central chest pain described as squeezing, radiating to his back, associated with sweating and clamminess. The pain lasted approximately one hour before subsiding. He remained pain-free during the day and went out for coffee. At 18:30 that evening, he experienced another episode lasting several hours. He went to bed but felt unable to lie flat due to coughing, with pain persisting. At 01:00 on 25/02/26, the pain returned and his wife persuaded him to attend hospital. He experienced further chest pain just prior to arrival in the Emergency Department.

During his attendance, he has experienced recurrent palpitations with heart rate fluctuating between 94-95 bpm in sinus rhythm and 160 bpm in SVT. Associated with these episodes, he reports complete loss of vision preceded by a loud banging sound, with vision returning after the episode resolves. These visual symptoms have occurred three times during his hospital attendance and have been present for the past two days. He describes the sensation as vision "creeping up" then suddenly disappearing with an audible bang, returning shortly after.

He reports a fall 2-3 months ago when a door hit him, causing him to fall backwards. Since then, he has experienced pain in his hands, neck, and left shoulder blade area, particularly when sitting upright reading.

Past Medical History:
• Ischaemic heart disease with coronary artery stenting (July 2020) - STEMI managed with primary PCI to OM1 with 2 stents
• Previous elective PCI to right RCA and distal/mid LAD with 2 stents for CCS Class 3 angina (June 2020)
• Bystander distal LAD and distal circumflex disease on medical management
• Small bowel obstruction (2021)
• Cholecystectomy (1990)
• Colonic diverticulosis
• Hypertension
• CKD Stage 3
• Primary open angle glaucoma
• BPPV
• Fractured neck of femur (2019) - treated with DHS
• Bilateral hip replacements
• Osteopenia

Drug History:
• Alendronic acid 70mg PO weekly
• Calcichew D3 1 tablet PO OD
• Furosemide 20mg PO OM
• Atorvastatin 40mg PO OD
• Aspirin 75mg PO OD
• Omeprazole 20mg PO OD
• Latanoprost 50 micrograms/ml eye drops, 1 drop to both eyes OD
• Lisinopril 10mg PO OD
• Isosorbide mononitrate (recently re-prescribed after brief cessation)

Allergy History:
Not documented

Social History:
Lives with his wife in a bungalow . Retired chauffeur, having worked in the family business established in 1924. He walks with a stick, able to manage 10-20 yards before stopping due to breathlessness and chest discomfort. Remains active with gardening activities. Ex-smoker, smoked approximately 20 cigarettes daily during his twenties, stopped due to chest problems. Previously drank whisky but no current alcohol consumption. Functionally independent with walking aid, manages activities of daily living with support from wife.

On Examination:
General Appearance: Alert 93-year-old gentleman, comfortable at rest, experiencing intermittent palpitations and visual disturbances.

Observations: HR fluctuating between 94-95 (sinus rhythm) and 160 (SVT), BP 102/77, RR 23, SpO2 97% on room air, Temperature not documented

• Cardiovascular: JVP not raised. Heart sounds heard. Palpitations noted during examination with associated visual symptoms when in fast rhythm.
• Respiratory: Lungs clear, slightly stiff as expected for age, adequate oxygenation maintained
• Abdomen: Soft, non-tender, passed urine, bowels opened this morning
• Neurological: Experiencing transient complete vision loss associated with arrhythmia episodes
• Musculoskeletal: Bilateral hip replacements noted, walks with stick

Investigations:
• Hb 113 (previously 115 in February 2025 and 109 in June 2025)
• Creatinine 156 (previously 128 in November 2025) - AKI Stage 1
• Urea 16.6
• ALT 50 (previously 9 in June 2025)
• AST 53
• CRP <1 (awaited at time of initial assessment)
• Troponin T 397 at 06:23, 207 at 02:48
• Coagulation screen: Awaited
• Venous blood gas: Normal
• Full blood count from 05:00: Normal
• LFTs: Normal apart from transaminitis

• CXR (26/02/26): Clear lung fields, mild left basal haziness at costophrenic angle, impression of increased bronchovascular markings bilaterally compared with 2023. Stable appearances compared with previous showing atelectasis in left lower zone.

• CT Thorax/Abdomen/Pelvis (July 2023): Background pulmonary fibrosis progressed compared to 2019, cholecystectomy noted, liver cyst, heavy aortic calcification, atrophic right kidney, faecal loading in rectum, uncomplicated colonic diverticulosis, bilateral hip replacements, osteopenia, degenerative spinal changes, no rib fractures

• ECG: Episodes of SVT with rate 160, reverting to sinus rhythm 94-95

Impression:
NSTEMI with dynamic troponin rise in context of pre-existing ischaemic heart disease with previous multi-vessel PCI. Recurrent paroxysmal SVT causing haemodynamic compromise with pre-syncope manifesting as complete vision loss. Likely culprit lesion requiring angiographic assessment. Mild AKI likely pre-renal. Incidental transaminitis requiring monitoring.

Differential Diagnoses: Acute coronary syndrome with arrhythmia, atrial fibrillation with rapid ventricular response

Management Plan:
1. Amiodarone infusion commenced for rhythm control with cardiac monitoring
2. CCU bed with telemetry for close monitoring of cardiac rhythm
3. Medical management of NSTEMI - continue dual antiplatelet therapy
4. VTE prophylaxis with fondaparinux
5. Discuss with cardiology regarding early angiography and consideration for further PCI
6. Anticoagulation decision in context of amiodarone therapy and possible atrial fibrillation - discuss whether fondaparinux alone sufficient or if additional anticoagulation required
7. Monitor renal function and fluid balance given AKI Stage 1
8. CCU/Cardiology bed
9. Escalation plan: For attempted CPR if clear reversible cause of arrhythmia given good baseline functional status. However, if prolonged resuscitation without reversible arrhythmic cause, for prompt cessation given advanced age. Plan discussed and agreed with patient.

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Summary:

Investigations:

Tasks

Feedback

• Missed opportunity to quantify pack-year smoking history more precisely - "20 cigarettes daily during twenties" is vague
• Visual symptoms described by patient warrant more detailed neurological examination beyond just observing JVP - formal cranial nerve examination and fundoscopy would be appropriate given glaucoma history
• Inadequate documentation of cardiac examination - no mention of murmurs, extra heart sounds, or peripheral pulses/perfusion status despite known IHD and AKI
• Allergy status completely undocumented - critical safety issue before prescribing
• No formal assessment of confusion/delirium risk factors documented despite patient's age and acute illness
• Medication reconciliation incomplete - isosorbide mononitrate dose not documented despite patient stating it was recently re-prescribed
• Safety-netting around visual symptoms inadequate - patient expressing concern about brain pathology but reassurance rather vague ("we can scan your head") without clear plan
• No documentation of capacity assessment for consent to procedures/investigations despite patient's age and cognitive function not formally assessed
• Social history lacks detail on formal care package, next of kin contact details, or ceiling of care discussions beyond CPR
• Communication style during resuscitation discussion could be clearer - multiple attempts to explain CPR in roundabout way rather than direct explanation

Refined clerking (45 days ago 11:23)

Refined clerking Fri 20 February 2026 11:23

Last Modified: 45 days ago

MRN:

Content:

{
  "mrn": "548198",
  "patient_name": "Jeffrey Tompkins",
  "content": "Medical ST5 Miller Clerking\n\nPresenting Complaint:\nChest pain / palpitations\n\nHistory of Presenting Complaint:\nJeffrey Tompkins is a 93-year-old gentleman with a significant cardiac background who presented to the emergency department in the early hours of the morning with recurrent chest pain and palpitations.\n\nHe gives a background history of exertional chest discomfort over the past year, consistent with his known ischaemic heart disease. This manifests as exertional dyspnoea and chest discomfort, limiting his walking to approximately 10–20 yards before he must stop. He had previously been on isosorbide mononitrate, which was stopped some weeks prior to this presentation; his GP had re-prescribed this approximately one to two weeks ago, though he had not yet taken the medication.\n\nThe acute presentation began yesterday morning. He awoke between 08:30 and 09:30 and developed central chest pain, which he described as a squeezing sensation radiating into the back, associated with diaphoresis. This episode lasted approximately one hour before subsiding spontaneously. He was pain-free throughout the remainder of the morning and went out for coffee. At approximately 18:30, a further episode of chest pain occurred lasting several hours. He then went to bed but felt unable to lie flat due to coughing. At approximately 01:00, chest pain returned and his wife persuaded him to attend hospital.\n\nOn arrival, he was noted by the radiographer to have a heart rate fluctuating up to 160 bpm consistent with a supraventricular tachycardia (SVT), reverting to sinus rhythm at 94–95 bpm at times. He reported palpitations occurring approximately every 90 seconds.\n\nIn addition to the cardiac symptoms, he reported two further issues of note. Firstly, he described recurrent brief episodes of complete visual loss in both eyes over the preceding two days, occurring up to three times during this admission, associated with an auditory phenomenon described as a loud bang, with full recovery of vision thereafter. These episodes appeared to correlate temporally with episodes of tachycardia, suggesting haemodynamically mediated cerebral hypoperfusion. Secondly, he reported left-sided neck and shoulder pain radiating up into the shoulder and neck, developing after an unwitnessed fall approximately two to three months ago in which he struck his head, was knocked off his feet and sustained a shoulder injury. He did not attend hospital at the time. This pain has been persistent since the fall.\n\nHe denied any calf pain or symptoms suggestive of peripheral vascular disease. He reported no claudication symptoms, attributing his limited mobility primarily to cardiac symptoms and his known hip replacements.\n\nHe is well known to cardiology with a history of previous percutaneous coronary intervention.\n\nPast Medical History:\n• Ischaemic heart disease — primary PCI to OM1 (×2 stents) July 2020; elective PCI to distal/mid LAD (×2 stents) June 2020 for CCS Class III angina; bystander distal LAD and distal circumflex disease managed medically\n• Fractured neck of femur 2019 — dynamic hip screw; bilateral hip replacements\n• Small bowel obstruction 2021\n• Cholecystectomy 1990\n• Colonic diverticulosis\n• Hypertension\n• Chronic kidney disease stage 3 (baseline creatinine ~128 µmol/L, November 2025)\n• Benign paroxysmal positional vertigo (BPPV)\n• Primary open-angle glaucoma\n• Background pulmonary fibrosis (noted on CT July 2023, progressed from 2019)\n\nDrug History:\n• Alendronic acid 70mg PO once weekly\n• Calcichew D3 1 tablet PO OD\n• Furosemide 20mg PO OD\n• Atorvastatin 40mg PO OD\n• Aspirin 75mg PO OD\n• Omeprazole 20mg PO OD\n• Latanoprost 50 micrograms/mL eye drops — 1 drop in both eyes OD\n• Lisinopril 10mg PO OD\n\nRecently Stopped Medications:\n• Isosorbide mononitrate — stopped several weeks ago; re-prescribed by GP approximately one to two weeks prior to this admission; patient had not yet recommenced\n\nAllergy History:\n• NKDA\n\nSocial History:\nLiving situation: Lives with his wife in a bungalow in the Birmingham area.\nMobility: Mobilises with a stick on occasion, though can walk short distances unaided. Limited to approximately 10–20 yards before stopping due to exertional dyspnoea. Managed stairs prior to admission.\nCarers: Wife present; family involved (son contactable by phone).\nOccupation: Retired. Previously worked as a chauffeur, a family business established by his father.\nSmoking: Ex-smoker. Smoked approximately 20 cigarettes per day during his twenties; stopped due to chest problems. Estimated pack years: approximately 5–10.\nAlcohol: Previous drinker (whisky); no longer drinks.\nFunctional Status: Independently mobile at baseline with moderate functional limitation due to cardiac symptoms. Able to manage activities of daily living and tends to the garden.\n\nOn Examination:\nGeneral Appearance: Alert and orientated. Cooperative and conversational throughout.\nObservations: HR fluctuating 94–160 bpm (SVT noted on monitoring), BP 102/77 mmHg, RR 23 breaths/min, O2 saturations 97% on air.\n\n• Cardiovascular: Heart rate irregular during examination with episodes of tachycardia correlating with reported visual symptoms. JVP not raised. Episodes of visual disturbance observed to correlate with tachycardic episodes during assessment.\n• Respiratory: Lungs auscultated — age-related stiffness noted. No acute concern identified clinically.\n• Abdomen: Abdomen examined — no significant findings documented.\n• Other: Bilateral hip replacements noted. Walks with a stick.\n\nInvestigations:\n• Haemoglobin (today): 113 g/L (previously 115 g/L June 2025, 109 g/L February 2025)\n• Troponin T (02:48): 207 ng/L\n• Troponin T (06:23): 397 ng/L (rising trend — consistent with myocardial injury)\n• Creatinine (today): 156 µmol/L (previously 128 µmol/L November 2025) — AKI Stage 1\n• Urea (today): 16.6 mmol/L\n• ALT (today): 50 U/L (previously 9 U/L June 2025)\n• AST (today): 53 U/L\n• CRP: <1 mg/L\n• Liver function tests: Otherwise normal\n• Full blood count: Otherwise normal\n• Venous blood gas: Normal\n• CRP (repeat): Awaited\n• Coagulation screen: Awaited\n• Chest X-ray (today): Clear lung fields; mild left basal haziness at the costophrenic angle; increased bronchovascular markings bilaterally compared with 2023. Previously noted left lower zone atelectasis — stable appearances overall.\n• CT Thorax/Abdomen/Pelvis (July 2023, indication: trauma): Background pulmonary fibrosis progressed from 2019; cholecystectomy noted; liver cyst; heavy aortic calcification; atrophic right kidney; faecal loading in rectum; uncomplicated colonic diverticulosis; bilateral hip replacements; osteopenia; degenerative spinal changes; no rib fractures.\n\nImpression:\nNSTEMI (rising troponin T with chest pain and known ischaemic heart disease) — likely precipitant for new-onset atrial fibrillation / SVT.\nAtrial fibrillation / SVT — haemodynamically significant, with episodes of visual loss likely representing haemodynamically mediated transient cerebral hypoperfusion during tachycardic episodes.\nAKI Stage 1 — on background CKD Stage 3, likely in context of reduced cardiac output.\nDifferential for visual episodes: haemodynamic compromise secondary to arrhythmia (most likely); vertebrobasilar insufficiency; occipital TIA — to be considered.\nLeft neck and shoulder pain following fall 2–3 months ago — requires assessment; cervical or shoulder pathology possible.\n\nManagement Plan:\n1. Continuous cardiac monitoring on CCU with close haemodynamic observation.\n2. Amiodarone infusion — commence for rate/rhythm control; long line to be arranged for administration.\n3. Anticoagulation and antiplatelet therapy as per cardiology advice (Dr Hayder):\n   - Apixaban 2.5mg PO BD — to provide anticoagulation for atrial fibrillation and NSTEMI cover.\n   - Clopidogrel 300mg PO OD loading dose.\n   - Aspirin 75mg PO OD — to be discontinued (ceased on commencement of above regimen).\n4. Commence nitrate therapy to ensure ongoing pain relief.\n5. Fondaparinux — continue for VTE and NSTEMI prophylaxis.\n6. Cardiology review — discuss suitability for further coronary angiography +/- repeat PCI in context of rising troponins and known coronary disease.\n7. Consider CT head if episodes of visual loss continue or cannot be fully explained by haemodynamic compromise alone, to exclude intracranial pathology.\n8. Monitor renal function closely given AKI Stage 1 on background CKD — review nephrotoxic medications as appropriate.\n9. Cardiology bed (CCU preferred given ongoing amiodarone infusion requirement and need for continuous monitoring).\n10. Escalation plan: For attempted resuscitation including CPR if there is a clearly reversible cause of cardiac arrest (e.g., arrhythmia). Patient and clinician agree that in the context of a reversible precipitant, active treatment is appropriate. However, in the event of prolonged resuscitation without identifiable reversible cause, prompt cessation of resuscitation agreed given advanced age. Patient engaged with and understood this discussion. Patient is NOT currently for ITU-level escalation — this was not explicitly discussed but would require senior review. DNACPR form to be completed formally.\n11. Involve family (wife and son) in ongoing communications regarding clinical progress and future planning.",
  "summary": "Jeffrey Tompkins is a 93-year-old gentleman with extensive ischaemic heart disease and previous PCI who presented with recurrent central chest pain and haemodynamically significant SVT/atrial fibrillation, with rising troponins consistent with NSTEMI. He is being admitted to CCU for amiodarone infusion, anticoagulation, antiplatelet therapy, and cardiology review regarding further coronary angiography.",
  "investigations": "Troponin T 02:48 on 26/02/2026: 207 ng/L\nTroponin T 06:23 on 26/02/2026: 397 ng/L (rising)\nHaemoglobin 26/02/2026: 113 g/L (previously 115 g/L June 2025; 109 g/L February 2025)\nCreatinine 26/02/2026: 156 µmol/L (previously 128 µmol/L November 2025) — AKI Stage 1\nUrea 26/02/2026: 16.6 mmol/L\nALT 26/02/2026: 50 U/L (previously 9 U/L June 2025)\nAST 26/02/2026: 53 U/L\nCRP 26/02/2026: <1 mg/L\nVenous blood gas 26/02/2026: Normal\nFull blood count 26/02/2026: Otherwise normal\nLiver function tests 26/02/2026: Otherwise normal (apart from elevated ALT/AST above)\nCoagulation screen: Awaited\nCRP repeat: Awaited\nChest X-ray 26/02/2026: Mild left basal haziness at costophrenic angle; increased bronchovascular markings bilaterally; stable compared with 2023 (previously left lower zone atelectasis).\nCT Thorax/Abdomen/Pelvis July 2023: Background pulmonary fibrosis (progressed from 2019); liver cyst; heavy aortic calcification; atrophic right kidney; faecal loading in rectum; uncomplicated colonic diverticulosis; bilateral hip replacements; osteopenia; degenerative spinal changes; no rib fractures.",
  "tasks": [
    {
      "item": "Arrange long line insertion for amiodarone infusion",
      "time_frame": "2026-02-20T13:00:00",
      "request": "Please arrange long line insertion for Mr Jeffrey Tompkins (MRN: 548198), a 93-year-old gentleman admitted to CCU with NSTEMI and SVT/atrial fibrillation. He requires a long line for administration of amiodarone infusion as per CCU nurse-in-charge recommendation. Peripheral access is not suitable for amiodarone due to risk of phlebitis. Please prioritise as infusion needs to commence urgently."
    },
    {
      "item": "Commence amiodarone infusion",
      "time_frame": "2026-02-20T13:00:00",
      "request": "Please prescribe and commence amiodarone infusion for Mr Jeffrey Tompkins (MRN: 548198), 93-year-old male admitted with NSTEMI and haemodynamically significant SVT/atrial fibrillation. HR noted up to 160 bpm on monitoring. To be administered via long line. Duration approximately 12 hours as per plan. Please refer to local amiodarone infusion protocol."
    },
    {
      "item": "Prescribe Apixaban 2.5mg PO BD",
      "time_frame": "2026-02-20T13:00:00",
      "request": "Please prescribe Apixaban 2.5mg PO BD for Mr Jeffrey Tompkins (MRN: 548198), 93-year-old male with new atrial fibrillation in the context of NSTEMI. Dose of 2.5mg BD recommended by cardiology (Dr Hayder) to provide dual coverage for AF anticoagulation and NSTEMI medical management. Note: Aspirin 75mg OD to be ceased concurrently."
    },
    {
      "item": "Prescribe Clopidogrel 300mg PO loading dose",
      "time_frame": "2026-02-20T13:00:00",
      "request": "Please prescribe Clopidogrel 300mg PO as a loading dose for Mr Jeffrey Tompkins (MRN: 548198), 93-year-old male with NSTEMI. Recommended by cardiology (Dr Hayder) as part of dual antiplatelet/anticoagulation strategy. Aspirin to be ceased on commencement. Ongoing dose to be determined following cardiology review."
    },
    {
      "item": "Discontinue Aspirin 75mg",
      "time_frame": "2026-02-20T13:00:00",
      "request": "Please discontinue Aspirin 75mg PO OD for Mr Jeffrey Tompkins (MRN: 548198) with immediate effect. Aspirin is to be ceased as per cardiology advice (Dr Hayder) on commencement of Apixaban and Clopidogrel loading for NSTEMI and atrial fibrillation management."
    },
    {
      "item": "Commence nitrate therapy for ongoing chest pain relief",
      "time_frame": "2026-02-20T13:00:00",
      "request": "Please prescribe isosorbide mononitrate (or equivalent nitrate as per cardiology/local protocol) for Mr Jeffrey Tompkins (MRN: 548198), 93-year-old male with NSTEMI and exertional chest pain. Previously prescribed isosorbide mononitrate by GP but not yet recommenced. Nitrates indicated to ensure ongoing pain relief during admission. Please liaise with cardiology regarding preferred agent and dose."
    },
    {
      "item":

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