Physician's Assistant

Patient Details

Refined clerking (298 days ago 10:16)

Refined clerking Thu 12 June 2025 10:16

Last Modified: 298 days ago

MRN:

Content:

# Medical ST4 Miller Clerking Template

## Presenting Complaint:
Unresponsive episode yesterday

## History of Presenting Complaint:
This 84-year-old gentleman was generally unwell yesterday and had his heel and toe dressing changed. On returning home, he felt "absolutely rotten" - not confused but generally unwell and "not with it". In the evening, his wife found him still in a chair having not gone to bed. When helping him into bed and lifting his legs, she noticed he had become unresponsive and she could not feel a pulse. Ambulance crew found low oxygen levels on arrival. The patient has no recollection of the episode.

No recent cough, cold or fever. Has noticed worsening shortness of breath recently despite using CPAP nightly for obstructive sleep apnoea. Also reports darkening stool colour on iron, not melaena.

## Past Medical History:
• Peripheral vascular disease - left popliteal artery 50-74% stenosis with non-healing left heel ulcer
• Persistent atrial fibrillation
• Type 2 diabetes mellitus with retinopathy and nephropathy - HbA1c: 56 mmol/mol (August 2024)
• Coronary artery disease - complex stenting left main stem and RCA (March 2019)
• Obstructive sleep apnoea on CPAP
• Hypertension
• Bilateral cataracts
• Background diabetic retinopathy

## Drug History:
**Current Medications:**
• Linagliptin 5mg PO OD
• Lansoprazole 30mg PO mane
• Isosorbide mononitrate MR 30mg PO OD (prescribed 60mg)
• Ramipril 5mg PO OD
• Spironolactone 25mg PO OD
• Rivaroxaban 15mg PO OD
• Dapagliflozin 10mg PO OD
• Clopidogrel 75mg PO OD
• Atorvastatin 80mg PO nocte
• Doxazosin 2mg PO OD
• Gliclazide MR 30mg PO OD
• Iron tablets OD (patient reports, not on GP record)

## Allergy History:
NKDA

## Social History:
**Living Situation:** Lives with wife who is main carer  
**Mobility:** Struggles to lift legs independently

## On Examination:
**General Appearance:** Alert, oriented  
**Vital Signs:** HR 64, BP 137/58, Temp 36.1°C, RR 17, O₂ sats 100% on 4L oxygen  
**Systematic Examination:**
• **Cardiovascular:** Soft systolic murmur (TR on TTE)
• **Respiratory:** Reduced air entry right base with dullness to percussion - ?pleural effusion
• **Peripheral:** Bilateral lower limb oedema to hips. Non-healing ulcers on left heel and toe, dressed appropriately
• **Abdominal:** Soft, non-tender

## Investigations:
**Laboratory Results:**
• Hb 77 g/L (was 112 in August 2024) - low MCV, low MCH
• WCC 8 × 10⁹/L
• Neutrophils 6.6 × 10⁹/L
• CRP 16 mg/L
• Creatinine 235 μmol/L (baseline 150 in August 2024)
• eGFR 21 mL/min/1.73m² (June 2023)
• Urea 19.2 mmol/L
• Potassium 5.9 mmol/L
• Calcium and phosphate: normal
• ALP 173 U/L
• Troponin 165 ng/L rising to 216 ng/L
• Magnesium 0.65 mmol/L (low)
• INR 1.8
• Blood gas: pH 7.32, CO₂ 5.35 kPa
• Blood glucose 9.1 mmol/L

**Imaging:**
• Echocardiogram (August 2024): Normal LV size, preserved systolic function (EF 60%), reduced longitudinal function, mild TR, dilated RA, low probability pulmonary hypertension, left pleural effusion, AF

## Assessment/Impression:
**Primary Diagnosis:** Syncopal episode secondary to fast atrial fibrillation with rate-related troponin rise  
**Secondary Issues:** 
• Iron deficiency anaemia with positive FIT test
• Acute kidney injury on chronic kidney disease
• Right pleural effusion causing hypoxia
• Fluid overload
• Hypomagnesaemia

## Management Plan:
1. [✓] Replace magnesium intravenously
2. [✓] Cardiology review for AF management
3. [✓] Check haematinics
4. [✓] Repeat echocardiogram
5. [✓] Chest X-ray to confirm pleural effusion
6. [✓] Increase diuretics cautiously with daily U&E monitoring
7. [✓] Continue iron supplementation - consider IV iron infusion after inflammatory markers settle
8. [✓] Conservative management of iron deficiency anaemia - colonoscopy deemed too high risk given cardiac comorbidities
9. [✓] Continue oxygen therapy until able to maintain saturations
10. [✓] CPAP overnight for OSA

## Follow-up:
Inpatient care for minimum 4-5 days. Discharge once oxygen requirements resolved and fluid balance optimised.

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Refined clerking (298 days ago 10:39)

Refined clerking Thu 12 June 2025 10:39

Last Modified: 298 days ago

MRN:

Content:

Medical ST4 Miller Clerking

## Presenting Complaint:
Unresponsive episode

## History of Presenting Complaint:
This 84-year-old gentleman presented following an unresponsive episode at home. Wife reports that yesterday evening he felt generally unwell, describing feeling "rotten" and "not right". During the night, whilst his wife was assisting him to bed and lifting his legs, he suddenly became unresponsive with eyes half open and appeared not to be breathing. Episode lasted approximately 15 minutes until ambulance arrival. No CPR but paramedics found low oxygen saturations.

ED team witnessed similar episode overnight with slow AF on monitor.

Increased shortness of breath over recent weeks, worse than his baseline dyspnoea.

Reports stools have become darker (on oral iron), not melaena.

Has chronic non-healing left heel ulcer.

## Past Medical History:
• Type 2 diabetes mellitus with retinopathy, nephropathy and vasculopathy
- HbA1c: 56 mmol/mol (August 2024)
• Chronic kidney disease - baseline creatinine 150 (August 2024)
• Persistent atrial fibrillation (previously paroxysmal)
• Coronary artery disease - complex stenting to left main stem and RCA (March 2019)
• Peripheral vascular disease - left popliteal artery 50-74% stenosis
• Obstructive sleep apnoea on CPAP
• Hypertension
• Bilateral cataracts

## Drug History:
• Linagliptin 5mg PO OD
• Lansoprazole 30mg PO OM
• Isosorbide mononitrate MR 30mg PO OD (prescribed 60mg)
• Ramipril 5mg PO OD
• Spironolactone 25mg PO OD
• Rivaroxaban 15mg PO OD
• Dapagliflozin 10mg PO OD
• Clopidogrel 75mg PO OD
• Atorvastatin 80mg PO ON
• Doxazosin 2mg PO OD
• Gliclazide MR 30mg PO OD

## Allergy History:
NKDA

## Social History:
Lives with wife. Wife assists with transfers  
Non smoker, no EtOH

## On Examination:
Alert, appears pale  
Observations: RR 17, sats 100% on 4L oxygen, BP 137/58, HR 64, Temp 36.1°C (afebrile), BM 9.1  
Soft systolic murmur (TR on TTE)
Reduced air entry right base, bibasal creps. 
Soft, non-tender
Dressed heel ulcer left foot

## Investigations:
• CRP: 16
• Creatinine: 235 (baseline 150 in August 2024)
• eGFR: 21 (was 31 on 05/06/2025)
• Urea: 19.2
• Potassium: 5.9
• Calcium: Normal
• Phosphate: Normal
• ALP: 173 U/L
• Troponin: 165 then 216
• Magnesium: 0.65 
• INR: 1.8
• Haemoglobin: 77 (was 112 in August 2024)
• Neutrophils: 6.6
• White cells: 8
• Blood gas pH: 7.32, CO2: 5.35 kPa
• Chest X-ray (25/06/2025): Moderate right and small left pleural effusions similar to August 2024, new hazy opacification to right upper zones
• Echocardiogram (August 2024): Normal LV size with preserved systolic function (EF 60%), reduced longitudinal function, mild TR, dilated RA, low probability pulmonary hypertension, left pleural effusion noted

## Impression:
Symptomatic bradycardia secondary to slow atrial fibrillation causing presyncope/syncope with secondary type 2 myocardial infarction  
- Decompensated CCF. Fluid overload with pulmonary and peripheral oedema
- Iron deficiency anaemia secondary to GI blood loss - not for further investigation
- Challenging fluid balance with clinical overload, oxygen requirement alongside AKI on CKD

## Plan:
1. Monitored bed
2. IV Mg replacement
3. Gentle diuresis with increased spironolactone to 50mg OD
4. Strict fluid balance monitoring
5. Continue DOAC and antiplatelet therapy
6. Inpatient 24h tape plus consideration of PPM if documented episodes
7. Check haematinics
8. Consider IV iron infusion once infection excluded (check CRP trend)
9. Echocardiogram
10. Daily U&Es to monitor renal function during diuresis
11. Continue CPAP overnight for OSA
12. DNACPR discussion completed - for active treatment of bradycardic peri-arrest but not for CPR or ITU
13. Suspend ACEi and dapagliflozin in AKI and acute illness

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Summary:

Investigations: