Physician's Assistant

Patient Details

Refined clerking (9 days ago 14:01)

Refined clerking Sat 28 March 2026 14:01

Last Modified: 9 days ago

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Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Shortness of breath

History of Presenting Complaint:
78-year-old lady with a history of cardiomyopathy and left bundle branch block, diagnosed in February 2025, presented with sudden onset shortness of breath whilst sitting watching television last night. She denied chest pain. She has had a dry cough and progressive exertional dyspnoea over the past few months, with reduced exercise tolerance. She was previously reviewed by Cardiology and reportedly asymptomatic at that time. Recent CT coronary angiography showed no obstructive coronary artery disease.

Past Medical History:
• Cardiomyopathy with left bundle branch block, diagnosed February 2025
• Hysterectomy, 1995
• Anxiety
• Depression

Drug History:
• Bisoprolol 1.25mg PO OD
• Lisinopril 2.5mg PO OD

Social History:
Lives with her partner in a house on the moor. She is a non-smoker. Drinks approximately 1 bottle of wine per night and has done so for many years. Previously walked up to 5 miles, but exercise tolerance has been reduced over the past few months.

On Examination:
Unwell with acute respiratory distress.
Observations: HR 85 bpm, BP 171/84 mmHg, SpO2 100%.
• Abdomen: Soft, non-tender.
• Cardiovascular: Heart sounds normal. Peripheral perfusion reduced with delayed capillary refill.
• Respiratory: Bilateral crepitations to the mid zones.
• Other: Thin and cachectic.

Investigations:
• WCC 14.8
• Neutrophils 12.92
• Hb 147
• Urea 5.6
• ALT 94
• AST 162
• ALP 138
• Bilirubin normal
• CRP 3
• NT-proBNP 17,105
• Arterial blood gas: pH 7.22, pCO2 6.6, pO2 10.5, glucose 14.4, lactate 3.9, base excess -7.9
• Venous blood gas: pH 7.14, lactate 6.2
• Coagulation screen: normal
• COVID PCR: negative
• Blood cultures: negative so far
• Bedside echocardiography: Grossly dilated, globally hypokinetic left ventricle with very high E/e', no pericardial effusion or tamponade.
• Chest X-ray: Kerley B lines, distended pulmonary vasculature and bilateral mid-zone haze in keeping with acute pulmonary oedema.
• CT coronary angiography (2025): No obstructive coronary artery disease.
• Echocardiogram January 2025: Impaired, bordering severely impaired LV systolic function in the presence of tachycardia; impaired diastolic function with elevated filling pressures at rest; regional wall motion abnormalities; moderately dilated LV with normal wall thickness; high probability of pulmonary hypertension; moderate mitral regurgitation; at least mild tricuspid regurgitation; mild aortic regurgitation.

Impression:
Acute pulmonary oedema secondary to decompensated heart failure on a background of cardiomyopathy.
Myocardial infarction felt less likely given recent CT coronary angiography showing no obstructive coronary artery disease.
Differential Diagnoses: NSTEMI/STEMI less likely.

Management Plan:
1. Admit for acute management of decompensated heart failure.
2. Commence IV diuresis.
3. Start nitrate infusion.
4. Commence CPAP for respiratory failure, with repeat gases in 1 hour.
5. Escalate to ITU and consider BiPAP if no improvement.
6. Insert urinary catheter for strict fluid balance monitoring.
7. Maintain bed rest and close nursing observation.
8. Request inpatient echocardiography.
9. Add troponin to bloods.
10. Monitor input/output closely and involve Cardiology as required.

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Refined clerking Sat 28 March 2026 14:01

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