Physician's Assistant

Patient Details

Refined clerking (28 weeks ago 06:17)

Refined clerking Mon 22 September 2025 06:17

Last Modified: 28 weeks ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Generally unwell and weak

History of Presenting Complaint:
Patient presents with general unwellness and weakness in the context of deteriorating Duchenne muscular dystrophy. Recent urine cultures from 09/16/2025 grew E. coli sensitive to amoxicillin, fosfomycin and nitrofurantoin, indicating urinary tract infection. Patient has experienced worsening renal function with urea rising to 2.2 from baseline of 0.5, and lymph function deteriorated to 17 from baseline of 3 (was 12 during recent admission). Blood count shows neutrophilia at 7.19. Patient has poor swallow due to muscular dystrophy with concerns about nutritional status and aspiration risk. There is evidence of left renal angle tenderness suggesting possible obstructed renal system with concomitant infection.

Past Medical History:
• Duchenne muscular dystrophy - non-ambulant since August 2016
• Scoliosis secondary to muscular dystrophy
• Osteopenia
• Sleep breathing disorder - trial of nocturnal non-invasive ventilation under respiratory team
• Coeliac disease (2007)

Drug History:
• Ferrous fumarate 140mg/ml oral solution 2 spoonfuls daily
• Budesonide/formoterol 100/6 micrograms 2 puffs OD-BD
• Spironolactone 12.5mg PO OD
• Enalapril 2.5mg PO BD
• Bisoprolol 0.5mg PO OD
• Salbutamol nebuliser solution to be inhaled BD PRN
• Carbocysteine 750mg PO TDS
• Salbutamol 100 micrograms inhaler 1-2 puffs QDS PRN
• Deflazacort 150mg tablets 2 TDS

Allergy History:
Not documented

Social History:
Lives at home with family support
Non-ambulant since August 2016
Requires assistance with activities of daily living
Functional Status: Significantly impaired due to advanced muscular dystrophy

On Examination:
General Appearance: Unwell, weak
Observations: HR 100, BP 111/69, Temp 36.5°C, RR 17, O2 sats 100%
• Cardiovascular: Scoliotic, good regular peripheral pulses, weak arms, hyperdynamic thrusting apex, normal heart sounds with systolic flow murmur heard throughout precordium
• Respiratory: Quiet lung bases bilaterally but no focal signs of chest infection
• Abdomen: Soft with left renal angle tenderness
• Other: No peripheral oedema, no rashes

Investigations:
• Potassium and sodium: Within normal range
• Lymph function: 17 (baseline 3)
• Urea: 2.2 (baseline 0.5)
• Neutrophils: 7.19
• Urine MC&S (09/16/2025): E. coli sensitive to amoxicillin, fosfomycin and nitrofurantoin

Impression:
Deterioration in muscular dystrophy secondary to urinary tract infection
Obstructed renal system with concomitant infection - raises possibility of infected obstructed kidney
Massively decreased nutrition in context of poor swallow due to muscular dystrophy

Management Plan:
1. IV antibiotics - Co-amoxiclav given comorbidity and unwellness
2. Urology review regarding potential for infected obstructed kidney
3. Analgesia for renal angle tenderness
4. Continue overnight BiPAP ventilation as tolerated
5. Laxatives and enemas
6. SALT review for swallow assessment
7. Dietetic review - consider tube feeding in short term
8. Input/output charting
9. Medical ward admission for ongoing monitoring

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Refined clerking (28 weeks ago 06:19)

Refined clerking Mon 22 September 2025 06:19

Last Modified: 192 days ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Generally unwell and weak

History of Presenting Complaint:
Leon presents with general unwellness and weakness in the context of recent admission for obstructing renal stone. Recent urine culture from 16/09/2025 grew E.coli sensitive to amoxicillin, fosfomycin and nitrofurantoin. Current presentation represents deterioration in muscular dystrophy secondary to urinary tract infection with possible infected obstructed kidney. Patient has developed renal angle tenderness and systemic unwellness suggesting progression from simple UTI. Nutrition has become significantly compromised due to poor swallowing related to muscular dystrophy progression.

Past Medical History:
• Duchenne muscular dystrophy
• Scoliosis, non-ambulant since August 2016
• Osteopenia
• Sleep breathing disorder - on nocturnal non-invasive ventilation
• Coeliac disease (2007)
• Recent admission 15-16/09/2025: 4mm left PUJ obstructing stone with moderate hydronephrosis, hypotensive episode with LVEF 61% on echo (previously 42% in February 2025)

Drug History:
• Ferrous fumarate 140mg/ml oral solution 2 spoonfuls daily
• Beclometasone 100mcg 2 puffs OD-BD
• Spironolactone 12.5mg PO OD (held due to hypotension)
• Enalapril 2.5mg PO BD (held due to hypotension)
• Bisoprolol 0.5mg PO OD
• Salbutamol nebuliser 1 ampoule BD PRN
• Carbocysteine 750mg PO TDS
• Salbutamol 100mcg inhaler 1-2 puffs QDS PRN
• Unknown medication 150mg tablets 2 TDS (stock issue January 2021)

Recently Stopped Medications:
• Enalapril and spironolactone - held by mother due to hypotension on advice from Derriford cardiology

Allergy History:
Not documented

Social History:
Lives with mother who provides care
Non-ambulant since 2016
Requires assistance with activities of daily living
Significant functional impairment due to Duchenne muscular dystrophy

On Examination:
Alert but appears unwell
Observations: HR 100, BP 111/69, Temp 36.5°C, RR 17, O2 sats 100%
• General: Scoliotic, weak arms, hyperdynamic thrusting apex
• Cardiovascular: Regular peripheral pulses, normal heart sounds with systolic flow murmur heard throughout precordium
• Respiratory: Quiet lung bases bilaterally, no focal signs of chest infection
• Abdomen: Soft with left renal angle tenderness
• Other: No peripheral oedema, no rashes

Investigations:
• Sodium and potassium: Within normal range
• Lymphocyte count: 17 (baseline 3, was 12 during recent admission)
• Urea: 2.2 (baseline 0.5)
• Neutrophil count: 7.19
• Urine MC&S (16/09/2025): E.coli sensitive to amoxicillin, fosfomycin, nitrofurantoin
• CT KUB (previous admission): 4mm left PUJ obstructing stone with moderate hydronephrosis
• Echocardiogram (previous admission): LVEF 61%

Impression:
Deterioration in muscular dystrophy secondary to urinary tract infection
Obstructed renal system with concomitant infection - possibility of infected obstructed kidney
Secondary issues: Massively decreased nutrition due to poor swallow secondary to muscular dystrophy progression

Management Plan:
1. IV antibiotics - Co-amoxiclav given comorbidities and systemic unwellness
2. Urology review regarding potential infected obstructed kidney
3. Analgesia for renal angle tenderness
4. Continue overnight BiPAP as tolerated
5. Laxatives and enemas
6. SALT review for swallowing assessment
7. Dietetic review - consider short-term tube feeding
8. Input/output charting
9. Medical ward admission with cardiology input if required

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

Summary:

Investigations: