Physician's Assistant

Patient Details

Refined clerking (34 weeks ago 03:25)

Refined clerking Mon 11 August 2025 03:25

Last Modified: 34 weeks ago

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Content:

Medical ST4 Miller Clerking

Presenting Complaint:
Generally unwell

History of Presenting Complaint:
This 79-year-old gentleman was well until today when he developed sudden onset weakness, lethargy and shaking whilst visiting his neighbour. He became unable to stand due to generalised weakness and felt unwell with fevers. He describes mild abdominal discomfort but no significant pain elsewhere. His urine has been dark (coca-cola coloured) and pungent with some urinary incontinence noted. He denies chest symptoms, headache, visual changes, rashes or change in bowel habit. He is currently on steroids prescribed by the arthritis clinic for polymyalgia rheumatica. Emergency services were called and he was brought to A&E where he was noted to have fever.

Past Medical History:
• Seronegative rheumatoid arthritis (2021)
• Undifferentiated inflammatory arthritis - treating as polymyalgia 15mg of  prednisolone
• Chronic fatigue syndrome (2021)
• Asbestos-related lung disease with pulmonary nodule (10mm left lower lobe, 2023)
• Obstructive sleep apnoea - mild (April 2024)
• Hypertension (2008)
• Osteoarthritis - multiple joints
• Right elbow arthroplasty (2014)
• Basal cell carcinoma - excised (2021)

Drug History:
• Tamsulosin 400mcg PO OD
• Omeprazole 20mg PO BD
• Atorvastatin 20mg PO OD
• Amlodipine 5mg PO OD
• Paracetamol 1g PO QDS PRN
• Prednisolone 15mg PO OD - for polymyalgia rheumatica (4 week course started 27th June 2025) - Plan to taper steroids - unclear plan of weaning - likely on 12.5mg OD now.
• Alendronate 70mg OW (4 week course started 27th June 2025)
• Theical T OD (4 week course started 27th June 2025)

Allergy History:
• NKDA

Social History:
Lives at home with wife. Independent with activities of daily living. Uses walking stick for mobility. Former electrician with occupational asbestos exposure. Non-smoker, non-drinker.

On Examination:
General Appearance: Alert but appears unwell, pyrexial
Observations: HR 124, BP 163/85, Temp 39.5°C, RR 19, O2 sats 96% on 4L nasal cannulae
• Cardiovascular: Hyperdynamic circulation, no murmurs audible
• Respiratory: Crepitations present, resonant to percussion
• Abdomen: Soft, non-tender, no organomegaly
• Neurological: Mild confusion, no neck stiffness
• Other: Some urinary incontinence noted, skin appears normal

Investigations:
• FBC: Hb 152, WCC 8.8, Neutrophils 8.2
• U&Es: Creatinine 106 (baseline 84), electrolytes normal
• LFTs: Bilirubin 26 (previously 19)
• Lactate: 1.7. CRP 54
• CXR (current): Right lower zone hazy opacification, left lower zone changes, small bilateral pleural effusions, evidence of asbestos-related lung disease, possible consolidation compared to previous CT
• CT Thorax (recent): Stable left lower lobe nodule, asbestos pleural disease changes, mild right lower lobe effusion, nodular soft tissue thickening in right lung base

Impression:
Community acquired pneumonia on background of asbestos-related lung disease
CURB65 - 2
Possibility of urinary tract infection given dark offensive urine and incontinence - but felt less likely given CXR findings
AKI stage 1

Management Plan:
1. PO Antibiotics to cover chest and urine [x] - Co-amox and Doxy
2. IV fluids for hydration and AKI [x]
3. Bladder scan +/- catheterisation if in urinary retention [_]
4. Blood cultures [/]
5. Urine culture [/]
6. Fatigue screen bloods given chronic symptoms [/]
7. Medical admission - short stay or AMU
8. COVID swab [x] negative
9. Full escalation discussed and agreed

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Refined clerking Mon 11 August 2025 03:25

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