Physician's Assistant

Patient Details

Refined clerking (240 days ago 23:22)

Refined clerking Sat 09 August 2025 23:22

Last Modified: 240 days ago

MRN:

Content:

Medical ST4 Miller Clerking

Presenting Complaint:
Wheeze and cough for several days

History of Presenting Complaint:
Mrs Hatton presented with worsening wheeze and cough over several days, which was particularly bad today. She reports producing white phlegm with her cough, which is not normal for her as she does not always have a cough. The wheeze varies day to day but has been generally worse recently. She denies fevers, chest pain, or swelling in her legs. No associated shivering or feeling hot and cold.

Past Medical History:
• COPD (2018)
• Atrial fibrillation (2021)
• Moderate to severe mitral regurgitation secondary to posterior mitral valve prolapse
• Essential hypertension (1995)
• Chronic kidney disease stage 3b
• Polymyalgia rheumatica (2017)
• Common bile duct calculus - ERCP with stone removal (February 2025)
• Cholecystitis (2023)
• Gastro-oesophageal reflux disease (2010)
• Osteoarthritis of knee (2002)
• Vaginal wall prolapse (2019)
• Previous urinary retention (January 2025)

Drug History:
• Spiolto Respimat 2.5mcg/dose BD inhaler
• Salamol 100mcg PRN inhaler
• Rivaroxaban 15mg PO OD
• Bisoprolol 1.25mg PO OD
• Furosemide 20mg PO OM
• Ramipril 2.5mg PO OM
• Famotidine 20mg PO BD
• Atorvastatin 20mg PO ON
• Carbimazole 5mg PO OD
• Ursodeoxycholic acid 500mg PO BD
• Oxybutynin 5mg PO OD
• Paracetamol 500mg PO QDS PRN
• Laxido Orange sachets BD PRN
• Glycerol 4g suppositories PRN
• Estriol 1mg/g vaginal cream twice weekly

Allergy History:
Not documented

Social History:
Lives at home with husband, they look after each other. Has been together many years. Previously worked in hotel industry. Has 3 children. Uses walking stick. Gets out daily and does own shopping with delivery assistance. Independent with activities of daily living.

On Examination:
General Appearance: Alert and cooperative
Observations: Not documented in detail
• Cardiovascular: Heart sounds heard, no specific findings documented
• Respiratory: Chest examination performed, described as "not too bad"
• Abdomen: Soft, no pain on palpation
• Lower limbs: Some swelling noted
• No rashes observed
• Waterworks and bowels functioning normally

Investigations:
• Bloods (05/08/2025): FBC normal, TSH 0.05 (low), T3 4.2, T4 15.9
• ERCP (21/02/2025): Successful stone removal from dilated bile duct
• CT Abdomen/pelvis (27/01/2025): Biliary dilatation with ductal calculi, bladder distension
• MRCP (13/12/2024): Biliary obstruction secondary to CBD calculus
• TTE (06/06/2022): Moderate to severe MR, LVEF 60-65%

Impression:
Infective exacerbation of COPD versus decompensated congestive cardiac failure

Management Plan:
1. Observations and monitoring
2. Blood tests including inflammatory markers, LFTs, NT-proBNP
3. ECG
4. Chest X-ray
5. Sputum MC&S
6. If infection proven - Doxycycline and prednisolone
7. Consider Furosemide if blood pressure tolerates
8. Short stay admission to medical ward
9. Not for escalation to ITU

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Refined clerking Sat 09 August 2025 23:22

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