Physician's Assistant

Patient Details

Clerking (319 days ago 05:24)

Clerking Thu 22 May 2025 05:24

Last Modified: 319 days ago

MRN:

Content:

Medical ST4 Miller Clerking

Presenting Complaint:
Breathlessness and cough.

History of Presenting Complaint:
- Increasing breathlessness, worse on exertion, particularly going upstairs.
- Reduced exercise tolerance; unable to do activities previously managed.
- Associated with a cough—initially productive of orange-brown sputum, now pale and more spitty.
- No nocturnal dyspnoea, no waking at night gasping for breath.
- Cough worse in the morning.
- Has asthma but never required steroids at home; has two inhalers.
- Recent RSV vaccination followed by suspected chest infection treated with steroids.
- Previously had severe COVID-19 infection causing significant functional decline.
- Leg swelling observed (was under virtual ward review for this).

Past Medical History:
- Asthma (annual spirometry at GP, last one noted to be ‘quite a bit’, details not specified)
- Pulmonary embolism (previously on anticoagulation)
- Severe COVID-19 infection (with prolonged recovery)
- No previous significant asthma exacerbations
- No mention of diabetes or other significant diagnoses

Medication History:
- Two inhalers for asthma (unspecified)
- No ‘rescue’ steroid packs at home
- Not currently on warfarin or direct oral anticoagulant

Allergic History:
- Allergic reaction to blood thinners (unspecified, possibly rivaroxaban or apixaban)

Social History:
- Lives alone in a house with stairs
- Daughter lives nearby and visits often
- Cat at home
- Former librarian
- Does not drive or drink alcohol
- Never smoked
- Uses a walking stick for confidence/mobility

On Examination:
- Slightly prolonged expiratory phase on auscultation, some improvement after misting mask
- No significant wheeze
- Peripheral oedema noted previously
- No abdominal tenderness, bladder and bowels normal
- Neck tenderness on palpation (old injury)

Investigations:
- CT scan: showed possible lung infection but not much evidence (exact findings not specified)
- Chest X-ray: no signs of pneumonia or significant chest infection
- Echocardiogram planned (not yet done)
- ECGs performed (yesterday and previous week)—no abnormality noted
- Blood tests for cardiac function normal

Impression:
Likely exacerbation of asthma—viral or post-infective, not classical pneumonia. Peripheral oedema with normal cardiac bloods (echo pending for further assessment).

Plan:
1. Nebulised bronchodilators via misting mask to open airways [_]
2. Arrange outpatient echocardiogram (‘jelly scan’) to assess cardiac function and rule out cardiac cause of leg swelling [_]
3. Continue monitoring for resolution of breathlessness and exercise tolerance [_]
4. Review inhaler technique and consider respiratory nurse review [_]
5. Consider further steroid therapy if symptoms persist or worsen [_]
6. Safety-net—advice to seek help if symptoms worsen or unable to cope at home [_]

----- 
Summary:
Elderly woman with history of asthma and previous severe COVID-19 presenting with breathlessness and cough, likely due to asthma exacerbation. Awaiting echocardiogram to further investigate leg oedema.

AI Diagnosis:
Acute exacerbation of asthma, most likely viral/post-infective, with peripheral oedema of uncertain origin (cardiac function appears normal on bloods).

AI Plan:
1. Nebulised bronchodilators as needed.
2. Echocardiogram to rule out heart failure.
3. Monitor symptoms closely; escalate if no improvement.
4. Review and optimise inhaler use.
5. Consider oral steroids if no improvement.
6. Advise urgent reattendance if acute deterioration.

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Clerking (316 days ago 01:06)

Clerking Sun 25 May 2025 01:06

Last Modified: 316 days ago

MRN:

Content:

```json
{
  "mrn": "F882284",
  "content": "Medical ST4 Miller Clerking\n\nPresenting Complaint:\nDecreased responsiveness, noisy breathing\n\nHistory of Presenting Complaint:\nFound unwell by care staff this morning. Less responsive with noisy breathing. Known aspiration risk. Only responsive to pain with ambulance crew, hypoxic, tachypnoeic. Evidence of vomit on clothing. No history from patient as unresponsive.\n\nPast Medical History:\n• Multiple lacunar infarcts (June 2024)\n• Post-stroke seizures (October 2024, April 2025, January 2025)\n• Left-sided weakness post-stroke\n• Aspiration pneumonia (June 2024)\n• Alcohol dependence\n• Not seen GP in 40 years prior to June 2024 presentation\n\nMedication History:\n• Atorvastatin 80mg PO mane\n• Baclofen 10mg PO BD\n• Clopidogrel 75mg PO mane\n• Docusate 100mg PO BD\n• Lansoprazole 15mg PO mane\n• Levetiracetam 1g PO BD\n• Thiamine 100mg PO BD\n• Oilatum 11% cream apply to skin PRN\n\nAllergic History:\nNot mentioned\n\nSocial History:\nLives in a care home\n\nOn Examination:\nGCS 11 (E3 V3 M5). No response to verbal stimulus. Warm to touch. Regular pulses. Soft systolic murmur, non-radiating. No peripheral stigmata of infective endocarditis in hands or toes. Left-sided weakness post-stroke. Abdomen soft and non-tender. Decreased breath sounds left base. Bilateral peripheral oedema to knees. Productive cough.\n\nInvestigations:\nBloods: Creatinine 97 (baseline), electrolytes normal, CRP 3, neutrophils 13.8, WCC 15.2, Hb 132, iron 1.9, LFTs normal, ABG normal\nChest X-ray: Poor quality film, slumped to left, no clear focal consolidation\nECG: Sinus rhythm, first degree AV block, rate 97\nEEG (January 2025): Sharp waves right frontotemporal region, excess irregular slow activity in similar distribution\nObservations: HR 100, SpO2 100%, RR 21, BP 145/71\n\nImpression:\nAspiration pneumonia\n\nPlan:\n1. Blood cultures if spikes fever [_]\n2. IV antibiotics [_]\n3. IV fluids [_]\n4. Paracetamol for temperature [_]\n5. Sputum culture [_]\n6. Catheter specimen of urine for culture [_]\n7. Saline nebuliser to aid expectoration [_]\n\n----- \nSummary:\n80-year-old man with post-stroke seizures and left-sided weakness, lives in care home, presents with decreased responsiveness and noisy breathing, likely aspiration pneumonia.\n\nAI Diagnosis:\nAspiration pneumonia in the context of known aspiration risk, post-stroke dysphagia and evidence of vomiting. Differential includes hospital-acquired pneumonia given recent admissions.\n\nAI Plan:\n1. Empirical broad-spectrum antibiotics (e.g., co-amoxiclav) to cover aspiration pathogens\n2. Oxygen therapy if required to maintain saturations\n3. IV fluid resuscitation\n4. Blood cultures before antibiotics\n5. Sputum culture and sensitivity\n6. Urine culture to exclude concurrent UTI\n7. Speech and language therapy assessment when stable\n8. Consider nasogastric feeding if unsafe swallow\n9. Regular chest physiotherapy\n10. Monitor for seizure activity given history",
  "summary": "80-year-old man with post-stroke seizures and left-sided weakness, lives in care home, presents with decreased responsiveness and noisy breathing, likely aspiration pneumonia.",
  "investigations": "Creatinine 97 (baseline), electrolytes normal, CRP 3, neutrophils 13.8, WCC 15.2, Hb 132, iron 1.9, LFTs normal, ABG normal. Chest X-ray: Poor quality film, slumped to left, no clear focal consolidation. ECG: Sinus rhythm, first degree AV block, rate 97. EEG January 2025: Sharp waves right frontotemporal region, excess irregular slow activity in similar distribution.",
  "tasks": [
    {
      "item": "Request blood cultures",
      "time_frame": "2025-05-25T14:06:00Z",
      "request": "Please take blood cultures if patient spikes fever. 80-year-old man with post-stroke seizures, found unresponsive with noisy breathing, suspected aspiration pneumonia. Currently on antibiotics."
    },
    {
      "item": "Request sputum culture",
      "time_frame": "2025-05-25T14:06:00Z",
      "request": "Please send sputum sample for culture and sensitivity. 80-year-old man with productive cough, decreased breath sounds left base, suspected aspiration pneumonia. Known aspiration risk post-stroke."
    },
    {
      "item": "Request urine culture",
      "time_frame": "2025-05-25T14:06:00Z",
      "request": "Please send catheter specimen of urine for culture. 80-year-old man with indwelling catheter, presenting with decreased responsiveness, to exclude concurrent UTI as source of infection."
    },
    {
      "item": "Follow up culture results",
      "time_frame": "2025-05-27T02:06:00Z",
      "request": "Review blood, sputum and urine culture results. Adjust antibiotic therapy according to sensitivities if required."
    }
  ],
  "feedback": "- Missed opportunity to document full neurological examination given history of stroke and seizures\n- No mention of seizure prophylaxis review despite recent seizures and current admission\n- Failed to ask about or document recent oral intake/feeding history given aspiration risk\n- No safety-netting advice documented for care home staff regarding seizure monitoring\n- Missed opportunity to clarify antibiotic choice - 'IV antibiotics' is too vague\n- No mention of DVT prophylaxis assessment despite reduced mobility\n- Failed to document capacity assessment or best interests discussion despite patient being unresponsive\n- No clear escalation plan or ceiling of care discussion documented"
}
```

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Email (314 days ago 15:01)

Email Tue 27 May 2025 15:01

Last Modified: 314 days ago

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