Physician's Assistant

Patient Details

Refined clerking (191 days ago 21:52)

Refined clerking Sat 27 September 2025 21:52

Last Modified: 190 days ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Decreased responsiveness

History of Presenting Complaint:
More unwell over 2 days, less oral intake, more drowsy

Acutely drowsy and less responsive with son this evening. Called ambulance. Hypoxic and hypotensive with crew.

Decision made to switch to palliative care by ED team soon after arrival.

Past Medical History:
• Metastatic small cell lung carcinoma - diagnosis January 2025, declined further active treatment March 2025
• Chronic obstructive pulmonary disease
• Rheumatoid arthritis
• Hip and knee OA
• Essential tremor
• Acquired hypothyroidism (1996)
• Peripheral vascular disease
• Osteopenia

Drug History:
• Morphine sulphate 10mg/5ml oral solution 2.5-5ml PO QDS PRN
• Paracetamol 1000mg PO PRN
• Celecoxib 100mg PO BD
• Lansoprazole 30mg PO OD
• Atorvastatin 40mg PO nocte
• Levothyroxine 100mcg PO OD
• Clonazepam 500mcg PO BD
• Sulfasalazine 500mg PO BD
• Primidone 50mg PO OD (morning) and 25mg PO OD (evening)
• TheiCal-D3 1000mg/880unit PO OD
• Escitalopram 20mg PO OD
• Trimbow inhaler 2 puffs BD via spacer
• Salamol inhaler 1-2 puffs QDS PRN

Allergy History:
NKDA

Social History:
Lives with son. Not coping well at home over last few months.

On Examination:
General Appearance: Comfortable lying in bed, responsive to pain only
Observations: HR 140, BP 135/74 (improved from 80/54), O2 sats 96% on high flow oxygen (previously 86% on air), feels hot to touch - febrile
• Cardiovascular: Bounding pulses, warm peripheries
• Respiratory: Bilateral Left > right lower zone coarse crepitations on auscultation
• Abdomen: Soft and non-tender
• Other: Staining on fingers, mild pitting peripheral oedema to knees bilaterally, dry tongue

Investigations:
• Blood cultures: Negative so far
• Sodium 155 (previously 141)
• Potassium 2.4 (previously 3.5)
• Creatinine 61 (previously 53)
• INR 7.7
• Haemoglobin 131
• Platelets 128
• Neutrophils 12.81
• ALT 111
• Albumin 33
• ALP 274
• Bilirubin 68
• Protein 48
• CRP 87
• Urea 10.6
• AST 126
• Venous blood gas: pH 7.49, lactate 5.1, glucose 5.9
• CT April 2025: Left superior mediastinal node reduced in volume, left upper disease significantly reduced, left lower lobe nodule stable, multiple small liver metastases more prominent than March but reduced compared to PET scan, subtle sclerotic changes at bone metastases sites suggesting treatment response

Impression:
Deterioration with likely left lower lobe pneumonia on background of metastatic small cell lung carcinoma
Profound electrolyte abnormalities, significant coagulopathy likely multifactorial with vitamin K deficiency and metastatic liver disease contributing

Management Plan:
1. Add on TSH to exclude thyrotoxic crisis/thyroid coma
2. Scale 2 oxygen saturations and oxygen therapy for comfort
3. Update next of kin - updated at bedside.
4. Just in case medications
5. TEP: WBC
6. Admission to hospital side room for ongoing palliative care
7. Any hospital side room

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Refined clerking (190 days ago 01:04)

Refined clerking Sun 28 September 2025 01:04

Last Modified: 190 days ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Generally unwell

History of Presenting Complaint:
Patricia presented with a 2-day history of general deterioration and poor oral intake. Over the past 48 hours, she has become progressively more unwell with reduced consciousness level this evening. She is now responsive only to pain. This deterioration has occurred on a background of known metastatic small cell lung carcinoma diagnosed in January 2025. She commenced palliative carboplatin and etoposide on 22/01/25 but declined further active oncological treatment when reviewed by oncology in March 2025. She has since been referred for palliative care with involvement from the Rowcroft community palliative care team. Her son reports she had been eating and drinking very little over the past couple of days before this acute deterioration.

Past Medical History:
• Metastatic small cell lung carcinoma - histological diagnosis January 2025
• Hypothyroidism

Drug History:
Just in case medications administered:
• Hyoscine
• Midazolam (1 dose given)

Allergy History:
Unknown

Social History:
Lives with her husband. Has a son who is her main family contact. Son has caring responsibilities for pets at home. The family have found the chemotherapy journey very difficult, with the patient becoming very unwell after the third cycle when herbal supplements ran out.

On Examination:
General Appearance: Comfortable in bed, unresponsive except to pain
Observations: HR 140, BP ambulance crew 80/54 improving to 135/74 in department, O2 sats 86% improving to 96% on oxygen
• Cardiovascular: Warm peripheries, bounding pulses, mild pitting peripheral oedema to knees bilaterally
• Respiratory: Left lower zone coarse crepitations on auscultation
• Abdomen: Soft and non-tender
• Other: Nicotine staining on fingers, dry tongue

Investigations:
• Blood cultures: Negative so far
• Sodium: 155 (previously 141)
• Potassium: 2.4 (previously 3.5)
• Creatinine: 61 (from 53)
• INR: 7.7
• Hb: 131
• Platelets: 128
• Neutrophils: 12.81
• ALT: 111
• Albumin: 33
• ALP: 274
• Bilirubin: 68
• Total Protein: 48
• CRP: 87
• Urea: 10.6
• AST: 126
• Venous Blood Gas: pH 7.49, lactate 5.1, glucose 5.9
• CT Cross-sectional imaging (April 2025): Left superior mediastinal node reduced in volume, left upper lobe disease significantly reduced, left lower lobe nodule stable, multiple small liver metastases more prominent than March but reduced compared to PET scan, subtle sclerotic changes at bone metastases sites suggesting treatment response

Impression:
Left lower lobe pneumonia on background of metastatic small cell lung carcinoma
Differential Diagnoses: Thyrotoxic crisis given profound electrolyte abnormalities and hypothyroidism background
Significant coagulopathy likely multifactorial secondary to vitamin K deficiency and metastatic liver disease
Profound electrolyte abnormalities
Terminal admission requiring palliative care

Management Plan:
1. Scale oxygen to saturations for comfort
2. Add on TSH to exclude thyrotoxic crisis
3. Just in case medications continued
4. Update next of kin
5. Complete formal DNACPR form
6. Admission to hospital side room for ongoing palliative care
7. Any bed - palliative care focused
8. Not for CPR, not for escalation as per ED team assessment - palliative care approach

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