Physician's Assistant

Patient Details

Refined clerking (35 weeks ago 04:35)

Refined clerking Mon 04 August 2025 04:35

Last Modified: 35 weeks ago

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Content:

Medical ST4 Miller Clerking

Presenting Complaint:
Chest pain

History of Presenting Complaint:
This 85-year-old lady from a care home presented with central chest pain which started yesterday afternoon. She described this as achy in nature, non-radiating, rated 5/10 severity. The pain was associated with shortness of breath on sitting. Care home staff noted her to be confused. She was given GTN prehospitally with suspicion of new congestive cardiac failure.

Care home staff also report fever.

The patient reports feeling better than yesterday and is currently pain-free. She denies any chest pain or SOB over the preceding weeks but has noted leg swelling.

Past Medical History:
• Hypertension
• Osteoarthritis (knees)
• Gastro-oesophageal reflux disease

Drug History:
• No current repeat medications

Allergy History:
• NKDA

Social History:
Lives in care home
Mobility: Unsure if uses aids spends most time in room
Never smoked
Does not drink alcohol

On Examination:
General Appearance: Alert, comfortable at rest, slightly confused (note early morning assessment)
Observations: HR 82, BP 142/65, RR 17, O2 sats 96%

• Cardiovascular: Heart sounds normal, pitting oedema to knees bilaterally
• Respiratory: Left basal crepitations
• Abdomen: Soft, non-tender
• Other: Tongue moist, patient reports severe leg swelling over past 2 weeks

Investigations:
• Troponin: 4,158 rising to 5,862
• CRP: 127
• Sodium: 130
• ALP: 155
• INR: 1.1
• White cells: 18.4 (neutrophils 15)
• Chest X-ray: Raised right hemidiaphragm, no focal consolidation, small left pleural effusion
• ECG: T wave inversion V3, sinus rhythm
• Urine samples: No infection

Impression:
Non-ST elevation myocardial infarction
Left lower respiratory tract infection/community acquired pneumonia

Management Plan:
1. Analgesia and GTN - patient to report any chest pain immediately
2. Medical admission
3. Medical management of NSTEMI - DAPT and Fonda
4. Antibiotics for pneumonia - oral amoxicillin
5. Cardiology PTWR

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Refined clerking Mon 04 August 2025 04:35

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