Physician's Assistant

Patient Details

Refined clerking (256 days ago 09:20)

Refined clerking Thu 24 July 2025 09:20

Last Modified: 256 days ago

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Medical ST4 Miller Clerking

Presenting Complaint:
Breathlessness for 3 weeks

History of Presenting Complaint:
Mr Ridge developed progressive breathlessness over 3 weeks, initially noticed when unable to walk upstairs without becoming severely short of breath. Episodes occur at rest and on minimal exertion, requiring him to go on hands and knees and lie down to recover. Associated with chest tightness described as "somebody tightening something around the chest" and palpitations. Has been using CPAP machine for sleep apnoea but continues to wake gasping for breath, requiring him to sit bolt upright and remove the mask. No chest pain but reports racing heart rate. Productive cough with yellow-green sputum changing to thick white/milky secretions over recent days, with some retching on Tuesday. No fever reported but feels generally unwell and unable to perform usual activities.

Significant background of Group B Streptococcus sepsis in 2016 requiring ITU admission with multi-organ failure, intubation, right empyema, AKI requiring haemofiltration, PEA arrest, and permanent pacemaker insertion. Persistent complex right pleural effusion remains. Atrial fibrillation developed following sepsis episode, currently managed with bisoprolol (total dose 3.75mg daily). Recently completed radiotherapy for prostate adenocarcinoma.

Secondary complaint of abdominal distension with pain under ribs and lower abdomen. Constipated - last bowel movement Tuesday morning after clearout for colonoscopy. Recent colonoscopy in June showed diverticulosis only.

Past Medical History:
• Permanent pacemaker insertion (2016)
Pacesetter St Jude - ENDURITY DR PM2162 
DDD(R)
• Prostate adenocarcinoma Gleason 7 (4+3) Grade Group 3 (2024) - treated with SABR radiotherapy and hormone therapy
• Group B Streptococcus sepsis with multi-organ failure, empyema, AKI requiring ITU admission (2016)
• Atrial fibrillation
• CKD Stage 2 (2021)
• Hypertension (2016)
• Severe sleep disordered breathing - on CPAP (July 2024)
• Erectile dysfunction (2012)
• Diverticulosis (2006)
• Complex right pleural effusion (persistent)

Drug History:
• Pregabalin 50mg PO TDS
• Tadalafil 10mg PO PRN
• Bisoprolol 1.25mg PO OD + 2.5mg PO OD (total 3.75mg daily)
• Adcal D3 1000/880 PO OD
• Lisinopril 5mg PO Nocte
• Atorvastatin 20mg PO Nocte
• Apixaban 5mg PO BD
• Indapamide 1.5mg MR PO Mane
• Beclomethasone 50mcg nasal spray BD
• Bicalutamide and Decapeptyl (continuing hormone therapy)

Allergy History:
• NKDA

Social History:
Lives with partner. Retired RAF serviceman with previous occupational exposure to possible asbestos (grey powdery substance around fuel tanks). Never smoked. No alcohol consumption. Currently housebound due to breathlessness. No dust exposure triggers symptoms.

On Examination:
General Appearance: Alert but distressed, unable to lie flat
Observations: Tachycardic with fast irregular pulse
• Cardiovascular: Heart sounds normal but fast and irregular, peripheral pulses present, pitting oedema to knees bilaterally
• Respiratory: Bibasal crepitations, coarser on right to mid-zones, wheeze audible
• Abdomen: Distended, tympanic, upper abdominal discomfort on palpation
• Other: No rashes on legs, hands normal

Investigations:
• CRP: 7
• Potassium: 3.3
• Magnesium: 0.68
• ALT: 76
• Bilirubin: 23
• INR: 1.2
• White cells: 5.9 (neutrophils 3.7)
• Venous blood gas: Mild alkalosis only
• Chest X-ray: Persistent complex right pleural effusion unchanged, new hazy bilateral opacification consistent with pulmonary oedema

Impression:
Atrial fibrillation with fast ventricular response leading to acute heart failure
Differential Diagnoses: Possible concurrent lower respiratory tract infection, electrolyte imbalance contributing to arrhythmia
Secondary issues: Constipation, known diverticulosis, persistent right empyema

Management Plan:
1. Cardiac monitoring and further stat bisoprolol for rate control
2. IV magnesium replacement (2g given) and IV potassium replacement
3. Laxatives for constipation
4. Recheck electrolytes including calcium and magnesium, TSH
5. Resume DOAC (apixaban)
6. Sputum MC+S and blood cultures to exclude infection
7. Short stay admission for rate control monitoring
8. Medical ward bed
9. Full escalation plan - TEP discussed

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Refined clerking Thu 24 July 2025 09:20

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