Physician's Assistant

Patient Details

Refined clerking (28 weeks ago 00:41)

Refined clerking Mon 22 September 2025 00:41

Last Modified: 28 weeks ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Confusion and dark urine

History of Presenting Complaint:
Presents with confusion and dark urine. Lives in a residential home with his wife. Both are planned for transfer to nursing care on Wednesday. Has a TEPP form stating not for admission apart from reversible causes, with a clear plan that he would like to stay at home. Daughter has lasting power of attorney for health. Carers from the residential home are concerned about his current presentation.

Past Medical History:
• Palliative care (August 2025)
• Blood in urine (July 2025)
• Housebound (October 2024)
• Basal cell carcinoma of skin (July 2024)
• Mixed dementia (November 2023)
• Atrial fibrillation (August 2022)
• Impaired left ventricular function (February 2022)
• Non-obstructive coronary atherosclerosis (February 2022)
• Heart failure with mid range ejection fraction (July 2021)
• Orthopnoea secondary to HFmrEF (July 2021)
• Mitral cusp prolapse (July 2021)
• Aortic root dilatation (February 2020)
• Mitral valve regurgitation (February 2020)
• High frequency hearing loss bilateral (January 2020)
• Is a carer for wife Vivien (November 2018)
• Mitral valve prolapse (August 2018)
• First degree atrioventricular block (March 2017)
• Essential hypertension (May 2000)

Drug History:
• Laxido Orange oral powder sachets 1-4 sachets PO daily
• Bisoprolol 2.5mg PO OD
• Rivaroxaban 20mg PO OD
• Candesartan 32mg PO OD
• Indoramin 20mg PO BD
• Atorvastatin 20mg PO OD

Allergy History:
Unknown

Social History:
Lives with wife in a house with package of care (unclear frequency). Due to move to nursing home with wife on Wednesday. Is a carer for his wife Vivien.

On Examination:
General Appearance: Unknown
Observations: Unknown
• Abdomen: No abdominal pain
• Cardiovascular: Clear ejection systolic murmur loudest in the aortic area, no peripheral oedema
• Other: No rashes

Investigations:
Unknown

Impression:
Possible urinary tract infection

Management Plan:
1. Agrees with ED Doctor's assessment
2. Oral antibiotics
3. Oral fluids
4. Aim for discharge home/nursing home as soon as possible

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Patient Details

Refined clerking Mon 22 September 2025 00:41

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