Physician's Assistant

Patient Details

Refined clerking (151 days ago 15:26)

Refined clerking Thu 06 November 2025 15:26

Last Modified: 151 days ago

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Medical ST5 Miller Clerking

Presenting Complaint:
Weakness and collapse

History of Presenting Complaint:
At 02:00, this 69-year-old gentleman went outside to let his dogs out. Upon returning to the kitchen, he attempted to rest on his wheeled stool but the stool gave way beneath him, causing him to fall. He was unable to get up independently. He reports progressive generalised weakness and finger tingling over recent months, coinciding with commencement of tirzepatide therapy.

He denies cough, chest pain, or other respiratory symptoms. He was found hypotensive by ambulance crew and brought to hospital.

Has had treatment with Abx and IV fluids.

Past Medical History:
• Chronic kidney disease stage 3
• Lumbar spinal stenosis - severe canal stenosis at L3/4 and L4/5
• Cervical spine degeneration with foraminal narrowing
• Previous acute kidney injury and community acquired pneumonia
• Atrial flutter 
• Bilateral posterior vitreous detachment
• Type 2 diabetes mellitus - latest HbA1c: 40 mmol/mol 
• Abdominal aortic aneurysm
• Peripheral vascular disease 
• Acute non-ST segment elevation myocardial infarction 
• Depression
• Arnold-Chiari syndrome

Drug History:
• Bisoprolol 1.25mg PO OD
• Lisinopril 2.5mg PO OD
• Tirzepatide 5mg/0.6ml SC weekly
• Co-codamol 30mg/500mg PO QDS PRN
• Apixaban 5mg PO BD
• Lansoprazole 15mg PO OM
• Pregabalin 300mg PO BD
• Furosemide 40mg PO OM
• Folic acid 5mg PO OD
• Metformin 500mg PO BD
• Citalopram 20mg PO BD
• Simvastatin 40mg PO ON

Allergy History:
Penicillin

Social History:
Lives with wife. Has 2 dogs. Ex-smoker from age 16-55 (approximately 60 pack years). Non-drinker currently.

On Examination:
Alert,
Observations: HR 75, BP 115 systolic (improved from 80), RR 15, O2 sats 93% on 3L oxygen
• Cardiovascular: Likely atrial fibrillation with rapid ventricular response on ECG, bilateral ankle oedema to knees, left leg chronically larger than right
• Respiratory: Right basal crepitations, no left-sided abnormality on auscultation
• Neurological: Reduced sensation in left foot, finger tingling reported
• Other: Chronic venous changes bilaterally, skin fragility with recent skin tear on left leg, wrist splint for chronic wrist pain, bowel movements twice weekly

Investigations:
• Creatinine: 164 (baseline 110) - AKI stage 1
• CRP: 29
• Urea: 13.8 (baseline circa 10)
• Hb: 116 (chronic anaemia since February 2025)
• Neutrophils: 13.69
• NT-proBNP: 1102 (March 2025)
• LFTs: Normal
• AST: Normal
• Venous blood gas: No acidosis
• Blood cultures: Negative so far
• Chest X-ray: Right basal hazy opacification, possibly small left pleural effusion, no evidence of right-sided pleural effusion

Impression:
Hypotension secondary to right community-acquired pneumonia (CURB-65 score of 3)
AKI stage 1
Long-standing anaemia of uncertain cause
Challenging fluid balance given clinical overload but persistent hypotension driven by sepsis
Limb numbness and weakness - likely diabetic neuropathy but to exclude other causes

Management Plan:
1. Continue IV antibiotics for community-acquired pneumonia
2. Maintain on 3L oxygen until saturations stable on air
3. Hold bisoprolol, lisinopril, and furosemide due to hypotension and AKI
4. Daily U&Es, input/output monitoring, urine dipstick
5. Start senna for constipation secondary to codeine
6. Thyroid function, B12, folate, vitamin D levels
7. Encourage mobilisation 
8. AMU

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Refined clerking Thu 06 November 2025 15:26

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