Physician's Assistant

Patient Details

Clerking (42 weeks ago 18:39)

Clerking Mon 16 June 2025 18:39

Last Modified: 42 weeks ago

MRN:

Content:

Medical ST4 Miller Clerking

Presenting Complaint:
Shortness of breath

History of Presenting Complaint:
6-month history of recurrent chest infections requiring multiple courses of antibiotics and steroids. 
Initially well until Christmas, then developed persistent productive cough with green-yellow sputum. 
Had significant deterioration in exercise tolerance - previously able to walk 3 miles without stopping in November, now struggles with 40 steps to front door. 
Recent travel to South Africa and Sri Lanka with marked worsening at altitude and during flights. Has had 3-4 courses of prednisolone over past 6 months. 
Recent course of levofloxacin caused Achilles tendon partial rupture.
Currently on oxygen with improvement in symptoms and colour. 
Bilateral leg swelling developed during holidays, right leg improved with compression stockings but left leg remains swollen.
Nil chest pain

Past Medical History:
• Asthma diagnosed age 16
• Bronchiectasis with Haemophilus influenzae colonisation
• Type 2 diabetes mellitus (06/11/2025) - likely steroid-induced
• Hypertension (02/2009)
• Basal cell carcinoma (2024)
• Achilles tendon partial tear secondary to levofloxacin
• Multiple fractures from cricket injuries

Medication History:
• Metformin 500mg PO at breakfast
• Trimbow Nexthaler 88/5/9 micrograms 2 puffs BD
• Atorvastatin 20mg PO ON
• Losartan 50mg PO OM
• Carbocisteine 750mg PO TDS
• Montelukast 10mg PO ON
• Amlodipine 5mg PO OD
• Terbutaline 500 micrograms 1 puff PRN QDS
• Trihexyphenidyl 1mg PO TDS (increase weekly by 1mg TDS to max 5mg TDS)

Allergic History:
Levofloxacin - tendonitis
Dust mites
Levofloxacin - tendonitis

Social History:
Retired primary school teacher. Previously very active including regular 3-mile walks. Minimal smoking history (5 cigarettes daily for 3-5 years, ceased years ago). Drinks alcohol socially. Family history of diabetes (father, maternal grandparents). Currently severely limited by breathlessness, spending most days sitting due to symptoms.

On Examination:
Normal heart sounds. 
Coarse crepitations to mid-zones bilaterally. No wheeze.
Left leg oedema to mid-thigh, right leg oedema to mid-shin. 
Sat 75% on room air, improved to 95-96% on oxygen 5L RR 21 BP 119/90 HR 91 T 37.0.

Investigations:
Sputum cultures: Haemophilus influenzae (intermittent growth) - most recent clear of H influenzae. Sensitive to doxycycline
Chest X-ray requested
Blood tests requested
CT pulmonary angiogram planned
Echocardiogram requested
BNP requested

Impression:
Recurrent infective exacerbation of bronchiectasis secondary to atypical bacterial or fungal pathogen. 
To rule out concomitant CCF, pulmonary embolism and malignancy as cause of respiratory deterioration.

Plan:
1. Blood tests including FBC, U&Es, CRP, D-dimer, NT-proBNP, HbA1c [/]
2. Monitor blood sugars on steroids
3. CTPA to exclude pulmonary embolism [/]
4. CT abdomen and pelvis (while in scanner given weight loss) [/]
5. Echocardiogram to assess cardiac function [/]
6. Commence anticoagulation pending CTPA result [x]
7. Doxycycline [/]
8. 5 days of Prednisolone 30mg OD [/]
9. Nebulisation [/]
10. Oxygen therapy targeting saturations 94-96% [x]
11. TEP: Full escalation

Field Clipboard (for EPR paste)

Builds copy buttons from the headings currently in the note, and also lets you copy the entire note.

Summary:

Investigations:

Tasks

Feedback

Clerking (42 weeks ago 18:29)

Clerking Mon 16 June 2025 18:29

Last Modified: 283 days ago

MRN:

Content:

Medical ST4 Miller Clerking

Presenting Complaint:
Shortness of breath

Past Medical History:
• Allergic asthma diagnosed age 16
• Achilles tendonitis secondary to levofloxacin (4 weeks ago)
• Recent diagnosis of diabetes (HbA1c elevated into diabetic range)
• Multiple previous fractures from cricket (fingers, ribs, thumbs)

Medication History:
• Salbutamol inhaler
• Tiotropium inhaler
• Prednisolone 30mg PO OD (recently completed 5-day course)
• Metformin (recently commenced for diabetes)
• Compression stockings PRN

Allergic History:
Dust mites
Levofloxacin (tendonitis)

Social History:
Lives in Cornwall. Retired primary school teacher. Previously very active - regular 3-mile walks. Ex-smoker (5 cigarettes daily for 3-5 years, ceased many years ago). Social alcohol intake. Recently travelled to South Africa and Sri Lanka. Currently housebound due to breathlessness.

On Examination:
Sat 75% on room air, improved to 95-96% on oxygen 5L RR 21 BP 119/90 HR 91 T 37.0
Bilateral lower limb oedema - right to mid-shin, left more extensive
Hands show evidence of previous cricket injuries
No wheeze audible
Improved colour and breathing on oxygen

Impression:
Most likely recurrent infective exacerbation of bronchiectasis secondary to atypical bacterial or fungal pathogen. 
Rule out concomitant CCF, pulmonary embolism and malignancy as cause of respiratory deterioration.

Plan:
1. Admit to respiratory ward [_]
2. Chest X-ray to exclude pneumonia [_]
3. CT pulmonary angiogram if chest X-ray clear [_]
4. Echocardiogram and BNP to assess cardiac function [_]
5. Blood tests including FBC, U&E, CRP, BNP [_]
6. Commence anticoagulation pending CT-PA result [_]
7. Commence appropriate antibiotic based on microbiology sensitivities [_]
8. Continue prednisolone course [_]
9. Nebulised bronchodilators and mucolytics [_]
10. Oxygen therapy to maintain sats 94-96% [_]
11. Respiratory ward - can go to resp bed prior to AMU PTWR.

Field Clipboard (for EPR paste)

Builds copy buttons from the headings currently in the note, and also lets you copy the entire note.

Summary:

Investigations: