Physician's Assistant

Patient Details

Refined clerking (64 days ago 19:56)

Refined clerking Sun 01 February 2026 19:56

Last Modified: 64 days ago

MRN:

Content:

Medical ST5 Miller Clerking
Sun 01 February 2026 19:56

Presenting Complaint:
Chest pain and confusion

History of Presenting Complaint:
This 77-year-old gentleman presented with recurrent chest pain and indigestion-like symptoms.

He was previously admitted on 30-31 January 2025 with non-cardiac chest pain and epigastric pain of sudden onset. CTA and troponins were negative during that admission.

He describes the current episode as similar indigestion-type pain, which has now resolved.

However, he appears confused and disoriented, not knowing his current location and mentioning "secret police" knowing where he is. He tells me he lives with his 70 year-old mother which seems unlikely.

Note previous admission where suffered with hallucinations, paranoia and was diagnosed with a delirium.

Loose stools according to nursing staff but patient does not report this.

Past Medical History:
• Atrial fibrillation
• Hypertension
• Delirium - March 2025
• CKD Stage 3
• Ischaemic heart disease - 2004
- TTE Jan 2026 - dyskinetic mid septal wall (EF 52%)
• Hypercholesterolaemia
• Angina - 2003

Drug History:
• Lansoprazole 30mg PO OD
• Amlodipine 5mg PO OD
• Apixaban 5mg PO BD

Allergy History:
• NKDA

Social History:
Unclear home circumstances, needs collateral. Unable to tell me of anyone I could call. Suggests I call his Mum.
Previously worked as a legal executive. Denies smoking or alcohol use
BUT note SHx from previous discharge summary: "Lives home alone, CFS 3. Smoked 20-30/day for 29 years, quit in his 50s.
Lifelong friend Mark lives in London. Cousin Michael is last surviving family 
but difficult relationship - lives nearby."

On Examination:
T 38.4, SPo2 97%, 130/84, RR 18, HR 75
General Appearance: Confused and disoriented, not knowing current location
Cardiovascular: Heart sounds normal
Respiratory: Normal chest auscultation
Abdomen: Soft, no specific findings noted
Neurological: Confused, disoriented to place, no focal neurology but not compliant with full examination. CAM +ve

Investigations:
• Sodium 130
• Creatinine 121 (baseline 88)
• Potassium haemolysed - AKI Stage 1
• Bilirubin 31 (previously 10)
• CRP 204 (from 56, previously 3)
• Urea 13.2 (previously 6.6)
• Hb 155 (stable)
• WCC 20.5
• Neutrophils 15
• VBG pH 7.34 with hypochloraemia and hyponatraemia
• CT Thorax (30/01): 4cm heterogeneous lesion in left superior retrosternal region, 12mm left adrenal nodule (30 Hounsfield units), mild fat stranding near pancreatic tail
• Chest X-ray: Clear lung fields
• ECG: AF with fast VR and LBBB QRS 152ms
- Known AF but unclear whether LBBB is new or old. Recent troponins normal

Impression:
Likely delirium secondary to infection of unclear source with acute kidney injury
Differential Diagnoses: Urinary tract infection vs pancreatitis vs cholangitis
Incidental adrenal nodule and retrosternal mass requiring outpatient investigation
Initially AF with fast VR, but now seems resolved.

Management Plan:
1. IV antibiotics including stat gentamicin - continue antibiotics
2. Blood tests including amylase, troponin and repeat haemolysed samples
3. Confusion screen bloods and CT head
4. IV fluids
5. Urine MC+S, dipstick for blood, catheterise, IO monitoring
6. Acute Medical Unit
7. TEP: DNACPR from previous admission
8. Outpatient referrals on discharge: Adrenal team for adenoma investigation, One-stop thyroid clinic for retrosternal mass

Bloods reviewed: Deranged LFTs, cholangitic pattern but I would have expected there to be some initial signs of this on the CT yesterday?

9. Antibiotics to cover cholangitis and urine
10. USS Liver vs MRCP to investigate this, probably best decided with view of the LFTs tomorrow. If more cholestatic and bilirubin continuing to rise then MRCP would be sensible

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:

Patient Details

Refined clerking Sun 01 February 2026 19:56

Field Clipboard (for EPR paste)

Tasks

Feedback