Physician's Assistant

Patient Details

Sdec (283 days ago 11:52)

Sdec Fri 27 June 2025 11:52

Last Modified: 283 days ago

MRN:

Content:

Presenting Complaint:
Respiratory symptoms with fever, haemoptysis, and dyspnoea

Past Medical History:
• ADHD
• Learning disabilities
• Laparoscopic salpingectomy 2022
• Domestic violence history
• Asthma
• PTSD
• Chronic widespread pain
• Functional neurological disorder (FND)
• IBS
• Migraines with functional seizures when unwell

Diagnosis:
Lower respiratory tract infection with acute exacerbation of asthma

I had the pleasure of meeting Ms Jarrold in Same Day Emergency Care today.

This 33-year-old lady presented with a 3-day history of fever (at home temperature 39.9°C), rigors, sweating, and feeling alternately hot and cold. She has experienced significant respiratory symptoms including productive cough with haemoptysis (bright red blood with brown sputum), dyspnoea, and sore throat. Her established asthma has deteriorated significantly, requiring increased use of her Symbicort inhaler from the prescribed 4 puffs BD to 8 times daily. She reports severe fatigue, unusual for someone who normally rises at 5am due to ADHD, and has been bedbound for several days. She also complains of severe headache, though she has a background of migraines and functional seizures when unwell.

On examination, heart sounds were normal. Chest examination revealed mild expiratory wheeze only. Obs RR 18, SpO2 99%, 127/90 BP, HR 77, T 36.6.

Her current medications include Symbicort 200/6 Turbohaler TT BD, Mirtazapine 15mg nocte, Phenergan 25mg nocte, Vitamin D, and Equasym XL 20mg OD.

Investigations:
Chest X-ray: Clear lung fields
Full Blood Count: White cells and neutrophils normal
ECG: Sinus rhythm, rate 81, no signs of ischaemia or pulmonary embolism

Plan:
1. Commence antibiotic therapy for lower respiratory tract infection if blood conducive
2. Optimise asthma management with bronchodilator therapy
3. Supportive care with paracetamol for fever and pain relief
4. Safety-netting advice regarding worsening symptoms
5. Follow-up with GP in 48-72 hours if symptoms persist
6. Return if breathing difficulties worsen or fever persists despite treatment

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Sdec (283 days ago 13:12)

Sdec Fri 27 June 2025 13:12

Last Modified: 283 days ago

MRN:

Content:

Presenting Complaint:
Fever, cough with haemoptysis, chest pain and back pain

Past Medical History
• ADHD
• Learning disabilities
• Laparoscopic salpingectomy 2022
• History of domestic violence
• Asthma
• PTSD
• Chronic widespread pain
• Functional neurological disorder (FND)
• IBS
• Migraines with functional seizures when unwell
• Spinal lump awaiting MRI

Diagnosis:
Viral upper respiratory tract infection (awaiting viral swab results)

I had the pleasure of meeting Lisa Gerald in Same Day Emergency Care today.

Ms Gerald is a 33-year-old lady who presented with a 3-day history of fever (maximum temperature 39.9°C), feeling hot and cold with rigors, productive cough with bright red haemoptysis and brown sputum, sore throat, and significant back pain. She reported increased breathlessness requiring increased use of her Symbicort inhaler from usual 4 puffs BD to 8 times daily. She also complained of severe headache and fatigue, noting she has been unable to get out of bed which is unusual for her given her ADHD.

On examination, she appeared unwell and was pyrexial to touch. Chest examination revealed no focal signs. Back examination demonstrated profound tenderness throughout the spine and lower chest/upper abdominal region, with a palpable tender lump in the spine for which she is awaiting MRI. No organomegaly was identified.

Investigations:
Chest X-ray: Clear lung fields
FBC: Normal white cells and neutrophils
CRP: <1
D-dimer: Negative
LFTs: Normal
Urea: Normal
Urine dipstick: Negative apart from trace blood
ECG: Sinus rhythm, rate 81, no signs of ischaemia or pulmonary embolism
Viral swab: Pending

Plan:
1. Outpatient ultrasound abdomen routinely
2. Additional blood tests: lipase, AST, GGT
3. Await viral swab results - will contact patient with outcome
4. GP letter regarding outstanding MRI spine referral
5. Follow-up appointment in 3 weeks when patient's childcare arrangements allow
6. Contact patient if any abnormal results on additional blood tests

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Summary:

Investigations: