Physician's Assistant

Patient Details

Refined clerking (88 days ago 00:18)

Refined clerking Thu 08 January 2026 00:18

Last Modified: 88 days ago

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Medical ST5 Miller Clerking
07/01/2026 23:35

Presenting Complaint:
Shortness of breath

History of Presenting Complaint:
This 86-year-old nursing home resident was admitted with worsening breathlessness, elevated respiratory rate, fever.

ECG showing acute anterolateral ST elevation myocardial infarction with initial blood pressure of 234 mmHg systolic. Hypoxic with oxygen saturations of 97% on 15 litres of oxygen. Chest X-ray demonstrated features consistent with pulmonary oedema including hazy increased interstitial markings and upper lobe diversion.

Patient discussed with cardiology but deemed unsuitable for primary PCI. Family aware of very poor prognosis.

Concurrent infection suspected given raised inflammatory markers and recent admission in December 2025 for pneumonia requiring IV antibiotics. Patient remains comfortable but with ongoing respiratory compromise and clinical signs of heart failure.

Past Medical History:
• Vascular dementia - MRI 2023 demonstrating multiple infarcts
• First seizure July 2024
• Fall April 2024 - rib fractures and pneumonia
• Dysphagia requiring thickened fluids
• Open angle glaucoma
• B12 deficiency
• Previous fragility fractures
• Benign prostatic hyperplasia 2019
• First degree atrioventricular block 2017
• Ischaemic heart disease 2002
• Angina 2000
• Hypertension 2000

Drug History:
• Ibuprofen 10% gel topical TDS-QDS
• Sodium valproate 200mg per 5ml oral solution - 7.5ml morning, 5ml afternoon
• Docusate oral solution 10ml BD
• Bisacodyl 5mg suppositories 1 each morning PRN constipation
• Lactulose 15ml BD PRN
• Cholecalciferol 400 units per ml oral drops - 2 drops daily
• Amitriptyline 25mg per 5ml oral solution - 1ml (5mg) at night
• Paracetamol 1g TDS-QDS PRN pain
• Thick and Easy powder for thickened fluids
• Circadin 2mg modified release tablets 1 at night
• Clopidogrel 75mg PO OD
• Latanoprost 50 microgram per ml eye drops - 1 drop both eyes OD
• GTN spray PRN

Allergy History:
NKDA

Social History:
Lives in nursing home with daily visits from wife. Requires hoisting for mobility but able to converse normally when well. Dependent for activities of daily living with formal care arrangements in place.

On Examination:
Warm to touch
Observations: HR 109, Temperature 37°C, RR 40, O2 sats 97% on 15L oxygen
• Cardiovascular: Normal heart sounds, mild peripheral oedema
• Respiratory: Increased respiratory rate, RLZ coarse crepitations

Investigations:
• Chest X-ray Poor quality film, hazy increased interstitial markings bilaterally with upper lobe diversion consistent with pulmonary oedema, likely pleural plaque left mid zone
• Troponin T 1225
• Liver function tests ALP 136, AST normal
• Full blood countWhite cells 13.7, lymphocytes 6.59, monocytes 1.58, otherwise normal
• U&EsCreatinine 49 (patient's baseline), sodium normal, urea normal
• CRP 50
• Venous blood gas Lactate 2.5, pH 7.31, potassium 4.5
• ECG Acute anterolateral ST elevation myocardial infarction

Impression:
Acute anterolateral ST elevation myocardial infarction with acute heart failure and pulmonary oedema
Concomitant community acquired pneumonia (right lower zone)
Poor prognosis, frailty

Management Plan:
1. Continue IV tazocin for suspected infection - MSU and sputum MC&S if producing
2. Medical ACS treatment - aspirin loading 300mg given, reload clopidogrel 225mg if able to swallow
3. IV furosemide for pulmonary oedema as tolerated by blood pressure
4. If in pain -> nitrate infusion but not in pain currently.
5. Stop IV fluids - clinically overloaded
6. Dual antiplatelet therapy - continue clopidogrel 75mg OD and aspirin
7. Cardiology ward admission
8. DNACPR in place, low threshold for palliation if deteriorates further

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Refined clerking Thu 08 January 2026 00:18

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