Physician's Assistant

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Content:

Medical ST5 Miller Clerking
Date/Time: 26/02/2025 11:22

Presenting Complaint:
Acute breathlessness

History of Presenting Complaint:
A 93-year-old gentleman presented via ambulance following acute onset breathlessness at approximately 03:30 this morning. He woke from sleep (sleeping on two pillows at baseline) with sudden breathlessness, initially thought to be a panic attack. Sitting upright did not provide relief. After approximately one hour, with no resolution, 111 was contacted and an ambulance dispatched.

Over the preceding few days, he had noticed a marked reduction in his exercise tolerance, needing to stop four to five times during a 20–30 minute walk that he would previously complete without difficulty. A nocturnal non-productive cough had also been noted over the last couple of nights. There was no associated chest pain.

On direct questioning, he denied orthopnoea beyond his usual two-pillow preference. There were no symptoms to suggest DVT.

Past Medical History:
• CKD stage 3
• Stroke 2021 (good recovery with no residual deficits reported)
• Diverticular disease (2012)
• Osteoarthritis
• Chronic anaemia — pattern consistent with anaemia of chronic disease; iron deficiency, folate, and B12 excluded (October–November 2025)
• Urinary catheter in situ (long-term, secondary to prostatic disease, since approximately 2023)

Drug History:
• Atorvastatin 20mg PO OD
• Clopidogrel 75mg PO OD
• Finasteride 5mg PO OD
• Tamsulosin MR 400micrograms PO OD
• Emollient dermal lotion (topical, as directed)

Allergy History:
NKDA

Social History:
Lives in a house with his wife. Manages stairs independently under normal circumstances.
Mobility: Uses a walking stick outdoors only (commenced approximately 3 months ago); independent indoors without aid. Prior to this acute presentation, able to walk 20–30 minutes without difficulty.
Carers: None — wife provides informal support.
Occupation: Retired.
Smoking: Ex-smoker. Smoked cigarettes for approximately 10 years, then switched to occasional cigars during working years. Ceased smoking approximately 30 years ago.
Alcohol: Non-drinker.

On Examination:
Observations: HR 104 bpm, BP 151/100 mmHg, O2 saturations 100% on 4L/min, RR 35 breaths/min.
Audible wheeze from the end of the bed.

• Cardiovascular: Heart sounds present, fast rate. No clearly audible murmurs. Mild pitting peripheral oedema to the knees bilaterally. Pulse regular to palpation with occasional PVCs corroborated on monitor.
• Respiratory: Silent left base to mid-zone. Percussion note dull to the left mid-zone. Right base dull to percussion with scattered coarse crepitations. Audible wheeze throughout both lung fields — most likely cardiac in aetiology.
• Abdomen: Soft and non-tender. No organomegaly. Urinary catheter in situ.

Bedside Investigations:
• ECG: Sinus rhythm with PVCs. No clear ischaemic changes on 12-lead ECG.
• Bedside Echocardiography: Globally hypokinetic, volume-overloaded left ventricle. Elevated EPSS. Mixed aortic valve disease with aortic valve calcification. No clear right heart strain.
• Lung Ultrasonography: Simple left-sided pleural effusion extending to the mid-zone. Small-volume right-sided pleural effusion. B-lines throughout both mid-zones bilaterally. A-lines seen at apices.

Investigations:
• Hb (October 2025): 121 — chronically anaemic
• Platelets: 516
• Neutrophils: 12.29
• WBC : 14.2
• Creatinine : 108 — at baseline
• Electrolytes : Normal
• LFTs : Normal
• CRP : 39 (previously 14 in November 2025)
• Urea : 5.8
• AST : Normal
• VBG : pH 7.23, Lactate 2.8, Base excess -2.6
• Ferritin (November 2025): 222
• Folate and B12 (October 2025): Normal
• Myeloma screen (November 2025): No paraprotein detected
• Blood cultures : No growth to date
• Chest X-ray : Bilateral lower zone opacification with increased bronchovascular markings to the mid-zones. Dense opacification and effusion on the left. Hazy opacification in the right mid-zone. Fluid in the fissure. Most consistent with acute pulmonary oedema

Impression:
Community-acquired pneumonia (CURB65 2) with parapneumonic effusion and congestive cardiac failure (likely precipitated by infection).

Differential Diagnoses:
1. Missed myocardial infarction leading to cardiac overload — less likely but cannot be excluded.

Management Plan:
1. Cardiac monitoring, 
2. Fluid balance charting
3. Wean oxygen as tolerated.
4. Repeat ECG
5. Add Troponin to prev bloods and recheck this am.
6. Treatment:
   a. IV furosemide
   b. Continue IV antibiotics
   c. VTE prophylaxis — pharmacological.
7. AMU bed
8. TEP as per ED team.

Summary:

Investigations:

Hb October 2025: 121 (chronically anaemic)
Platelets 26/02/2025: 516 (elevated; normal in May 2025)
Neutrophils 26/02/2025: 12.29
WBC 26/02/2025: 14.2
Creatinine 26/02/2025: 108 (at patient baseline)
Electrolytes 26/02/2025: Normal
LFTs 26/02/2025: Normal
CRP 26/02/2025: 39 (previously 14 in November 2025)
Urea 26/02/2025: 5.8
AST 26/02/2025: Normal
VBG 26/02/2025: pH 7.23, Lactate 2.8, Base excess -2.6
Ferritin November 2025: 222
Folate and B12 October 2025: Normal
Myeloma screen November 2025: No paraprotein detected
Blood cultures 26/02/2025: No growth to date
Chest X-ray 26/02/2025: Bilateral lower zone opacification with increased bronchovascular markings to mid-zones; dense opacification and effusion on the left; hazy opacification in the right mid-zone; fluid in the fissure
ECG 26/02/2025: Sinus rhythm with PVCs; no clear ischaemic changes (earlier rhythm: AF with rapid ventricular response)
Bedside Echocardiography 26/02/2025: Globally hypokinetic volume-overloaded left ventricle, elevated EPSS, mixed aortic valve disease, no right heart strain
Lung Ultrasonography 26/02/2025: Simple left-sided pleural effusion to mid-zone; small-volume right pleural effusion; bilateral mid-zone B-lines; apical A-lines

Patient Details

Refined clerking Wed 25 February 2026 11:22

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