Physician's Assistant

Sdec (37 weeks ago 16:00)

Sdec Mon 21 July 2025 16:00

Last Modified: 37 weeks ago

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Email (283 days ago 12:29)

Email Fri 27 June 2025 12:29

Last Modified: 283 days ago

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Issues review (130 days ago 20:01)

Issues review Thu 27 November 2025 20:01

Last Modified: 130 days ago

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Issues:
1. Diabetic ketoacidosis (DKA)
- Patient ran out of long-acting insulin over the weekend
- Prescription delay - ordered over a week ago but not dispensed
- Has been managing with short-acting insulin only
- Currently on DKA treatment

2. Type 3 diabetes secondary to recurrent pancreatitis
- Diagnosed 2012
- History of recurrent pancreatitis
- Takes Lantus 60 units nocte and rapid-acting insulin 13 units TDS with meals
- Uses Libre sensor for glucose monitoring
- Takes pancreatic enzymes

3. Right big toe ulcer with possible infection
- Hit toe initially, developed blisters
- Area of skin breakdown on medial aspect of right big toe
- Mild inflammation present
- Dressed for 13 days
- Patient has diabetic neuropathy - reduced sensation in feet

Background:
Patient is a gentleman with Type 3 diabetes secondary to recurrent pancreatitis since 2012. Lives with wife and 23-year-old daughter. Non-smoker, stopped drinking years ago due to pancreatic issues. Previous cholecystectomy (keyhole). Currently admitted with DKA following interruption of long-acting insulin supply.

Examination findings:
Chest: Normal heart sounds, clear lung fields
Abdomen: Soft, non-tender. Previous laparoscopic cholecystectomy scars
Feet: Reduced sensation bilaterally (diabetic neuropathy). Right big toe with area of skin breakdown on medial aspect, mild inflammation but not hot to touch
Hydration: Tongue appears dry, clinically dehydrated

Impression:
1. Diabetic ketoacidosis secondary to insulin omission
2. Type 3 diabetes mellitus secondary to chronic pancreatitis
3. Right big toe ulcer with possible secondary infection
4. Diabetic peripheral neuropathy
5. Mild dehydration

Plan:
1. Continue DKA treatment protocol
2. Monitor blood glucose and ketones - may discontinue IV insulin if numbers improve by evening
3. Restart long-acting insulin (Lantus 60 units nocte)
4. Additional IV fluid for rehydration
5. Urgent diabetic foot team referral for right big toe assessment
6. Ensure adequate insulin prescription to prevent future DKA episodes

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Refined clerking (129 days ago 19:06)

Refined clerking Fri 28 November 2025 19:06

Last Modified: 129 days ago

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Medical ST5 Miller Clerking

Presenting Complaint:
Collapse and confusion

History of Presenting Complaint:
This 89-year-old gentleman was well until this morning when he woke up fine and got dressed normally. He then developed what he described as the worst headache he had ever experienced. Later in the afternoon, whilst standing at the window, he collapsed and was found on the floor by his grandson who was working in the garden. He was unable to get up from the floor and appeared confused, asking questions like "how did I get here?" and "why haven't I been able to get up?". There was associated urinary incontinence and he has been noted to be mildly pyrexial. He appears to have weakness causing him to lean to the right side consistently. His son confirmed he sounded normal when spoken to over the phone this morning, indicating an acute onset.

Past Medical History:
• Hip problems (previous injury affecting mobility)
• Uses walking stick for mobility
• Independent living with stair lift installed

Drug History:
Unknown

Allergy History:
Unknown

Social History:
Lives independently in own home with stair lift installed. Usually very independent but uses a walking stick for mobility. Has family support from son and grandson who live nearby.

On Examination:
General Appearance: Alert, cooperative gentleman who appears unwell
Observations: BP 170/? systolic, mildly pyrexial
• Neurological: Glasgow Coma Scale appears intact - orientated to person and month (initially said November, corrected to August). Good bilateral hand grip strength. No obvious focal neurological deficit on formal testing. Cranial nerves II-XII grossly intact. No visual field defects. Facial symmetry normal. Upper and lower limb power appears symmetrical bilaterally. Finger-nose-finger test normal. Sensation intact to light touch. Tendency to lean to the right when sitting upright, described as feeling like being "on a ship". No obvious facial droop.
• Other systems: Not formally examined

Investigations:
CT head scan requested - pending

Impression:
Acute neurological event in 89-year-old gentleman
Differential Diagnoses: Stroke, intracranial haemorrhage, urinary tract infection with delirium, medication-related confusion, metabolic disturbance

Management Plan:
1. Urgent CT head scan to exclude intracranial pathology
2. Full blood count, urea and electrolytes, inflammatory markers, urinalysis
3. ECG and chest X-ray
4. IV access and baseline observations monitoring
5. Neurological observations 4-hourly
6. Consider antiplatelet therapy pending scan results
7. Medical ward admission for further investigation and monitoring
8. Escalation plan to be discussed with patient and family regarding resuscitation status

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Sdec (37 weeks ago 16:16)

Sdec Mon 21 July 2025 16:16

Last Modified: 37 weeks ago

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Presenting Complaint:
Lower gastrointestinal bleeding

Past Medical History:
• Not documented

Diagnosis:
Lower gastrointestinal bleeding, likely colonic angiodysplasia

I had the pleasure of meeting this patient in Same Day Emergency Care today.

The patient presented with a 3-4 day history of feeling unwell in the mornings, improving by late afternoon. They reported dark stools with episodes of bright red blood mixed in, describing the toilet water as appearing like "upset beetroot" after defaecation. The bleeding was not always visible in the stool itself but was evident in the toilet bowl.

On examination, chest was clear with normal heart sounds and no adjacent systolic murmur. Abdomen was soft and non-tender.

Blood results showed a significant drop in haemoglobin from 94 to 79 g/L, with platelets falling from 150 to 131. Previous haemoglobin in July 2024 was 139 g/L. CRP was normal and iron studies showed iron of 0.9.

Investigations:
OGD October 2024: Small gastric diverticulum, no other abnormalities
CT TAP: No cause for haemoglobin drop identified, no radiological evidence of malignancy
FBC: Haemoglobin 79 g/L (down from 94), platelets 131 (down from 150)
Iron studies: Iron 0.9
CRP: Normal

Plan:
1. Transfuse 1 unit of packed red blood cells
2. Refer to Surgical Assessment Unit for admission
3. Consider 2-week wait colonoscopy on discharge to investigate and potentially treat lower GI bleeding

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Sdec (258 days ago 17:03)

Sdec Tue 22 July 2025 17:03

Last Modified: 258 days ago

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Presenting Complaint:
Collapse in bank

Past Medical History
• Hypertension - on Amlodipine 5mg OD
• Kidney impairment (chronic)
• Previous collapse 2 years ago in June at home with head injury
• Memory loss

Diagnosis:
Syncope - cause to be determined

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

Anthony presented following a collapse in the bank this morning at approximately 09:30. He was queuing for about 30 minutes when he felt a little dizzy and then collapsed. He regained consciousness quickly (within seconds to minutes) and was not confused. He had only had coffee and biscuits for breakfast, which is his usual. There was no chest pain, palpitations, or head injury. He denies any recent illness, sore throat, or feeling unwell.

This is not the first episode - he had a similar collapse 2 years ago in June at home which resulted in a head injury. He also reports experiencing dizziness when getting up from lying to sitting position. He has no history of cardiac problems or diabetes.

O/E: Chest examination was normal with clear breath sounds bilaterally. No obvious injuries noted.

Recent blood tests show kidney impairment (chronic, not new) and slightly raised white cell count. Other inflammatory markers not significantly elevated.

Investigations:
Blood tests: Kidney impairment (chronic), slightly raised white cell count, other inflammatory markers normal

Plan:
1. 24-hour Holter monitor (can be fitted as outpatient)
2. CT head
3. Postural blood pressure measurements (lying and standing)
4. Follow-up with results and further management as indicated

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Sdec (256 days ago 18:00)

Sdec Thu 24 July 2025 18:00

Last Modified: 256 days ago

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Presenting Complaint:
Left shoulder and chest pain.

Past Medical History
• Type 2 diabetes mellitus (on Metformin and Gliclazide)
• Ischaemic heart disease with 2 coronary stents fitted
• Previous angiogram showing 2 blockages on return side of heart and 1 small additional blockage

Diagnosis:
Musculoskeletal chest wall pain

I had the pleasure of meeting this patient in Same Day Emergency Care today.

This gentleman presented with a 4-day history of left shoulder and chest wall discomfort which began on Sunday evening. The pain is described as a constant ache rather than sharp pain, radiating from the left shoulder down the upper arm and left side of chest. The discomfort is exacerbated by walking and arm movement, but notably improves when he holds his arm still against his body. He reports no shortness of breath or palpitations, though his heart rate monitor shows elevated readings of 135-140 bpm when walking uphill compared to his normal 72 bpm. He played golf on Saturday without issues and can walk uphill without respiratory symptoms.

O/E chest wall tenderness was noted on palpation, specifically in the left shoulder/upper chest area. Movement of the arm and shoulder reproduces the discomfort. No other examination findings were documented.

His blood pressure readings have been gradually increasing since Sunday as part of monitoring for his diabetes medication review.

Relevant past medical history includes type 2 diabetes and ischaemic heart disease with previous coronary stents. He describes this current pain as completely different from his previous cardiac symptoms.

Investigations:
Chest X-ray 25/07/24: Normal
Full blood count 25/07/24: Normal
U&Es 25/07/24: Normal
LFTs 25/07/24: Normal
ECG 25/07/24: Normal
Troponin: Pending

Plan:
1. Await troponin result
2. Discharge home if troponin negative
3. Simple analgesia for musculoskeletal pain
4. Follow-up with GP if symptoms persist or worsen

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Refined clerking (2 days ago 20:48)

Refined clerking Sat 04 April 2026 20:48

Last Modified: 2 days ago

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Medical ST5 Miller Clerking
04/04/2026 20:48

Presenting Complaint:
Left-sided abdominal pain

History of Presenting Complaint:
Presented following recent blood tests requested by GP after an episode of nausea and fever approximately 2 to 3 weeks ago, which settled with paracetamol and fluids at home. Since then, developed left lower abdominal pain, not typical of biliary colic. Also reported breathlessness, cough, pins and needles in fingers and toes, and a brief episode of dizziness with difficulty walking in a straight line, which has now improved.

She is a carer for her sister, who has Down syndrome. She had been taking an immune supplement, Biocare Immune. No recent travel, tattoos, alcohol or drug use. No recent antibiotics or medication changes.

Past Medical History:
• Turner syndrome
• Hypothyroidism
• Hysterectomy

Drug History:
• Levothyroxine
• Citalopram
• Biocare Immune supplement

Allergy History:
• No known drug allergies

Social History:
Lives with her partner. Carer for her sister with Down syndrome. Non-smoker. No illicit drug use. No recent alcohol intake.

On Examination:
Alert and comfortable at rest.
Observations: Not recorded
• Abdomen: Soft, with mild left-sided lower abdominal tenderness. No guarding. Murphy's sign negative. No dysuria. Bowel habit normal this morning. No vaginal discharge.
• Cardiovascular: Heart sounds normal. Peripheral pulses present.
• Respiratory: Chest clear on auscultation.
• Neurological: No focal neurological deficit elicited.

Investigations:
• Blood tests: Mildly deranged liver function tests with elevated ALP and other liver enzymes. Bone profile abnormal due to ALP, with normal calcium. Other markers for significant liver disease normal.

Impression:
Mild transaminitis with raised ALP, likely reactive to recent viral illness. Differential diagnoses: biliary obstruction/choledocholithiasis, gallstones, viral hepatitis.

Management Plan:
1. Arrange repeat liver function tests tomorrow.
2. Arrange viral screen including EBV and CMV.
3. Organise abdominal ultrasound to assess biliary tree and gallbladder.
4. No antibiotics indicated at present as there is no evidence of bacterial cholangitis.
5. Consider chest X-ray if breathlessness persists or needs further assessment.
6. If clinically well and investigations can be arranged, discharge home with follow-up for imaging and blood tests.

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Referral (208 days ago 11:33)

Referral Wed 10 September 2025 11:33

Last Modified: 208 days ago

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Investigations:
CT scan abdomen and pelvis: No acute pathology identified, 11mm lymph node noted in right upper abdomen
Ultrasound scan: No significant abnormalities, possible small ovarian cyst
Blood tests: Potassium normal, evidence of dehydration
Stool samples: No infection detected on initial testing
Chest X-ray: Performed

Thank you for asking me to review this patient who has been admitted under your team with severe gastroenteritis.

This patient presented on Monday with acute onset vomiting which progressed to profuse watery diarrhoea (Bristol stool type 7). She reports 8 episodes since Friday night, with associated severe abdominal pain initially requiring morphine analgesia. The pain was predominantly right-sided lower abdominal, worse on movement, causing her to adopt a foetal position. She has never experienced symptoms of this severity before.

She has been taking Mounjaro (semaglutide) for 8 weeks, which can rarely cause pancreatitis. She has a previous history of pancreatitis secondary to UTI and subsequent antibiotic treatment. She denies recent travel, dietary indiscretions, or contact with unwell individuals. She does not smoke and works in sport.

On examination, she appears dehydrated with difficult venous access noted. No palpable lymphadenopathy detected.

Imaging has been reassuring with no acute surgical pathology. The 11mm lymph node in the right upper abdomen is likely reactive secondary to gastroenteritis. The small ovarian cyst is incidental and would not account for her GI symptoms.

Impression:
Severe gastroenteritis, likely infective cause despite negative initial stool cultures
Dehydration
Reactive lymphadenopathy

Suggest:
1. Repeat stool sample for comprehensive microbiology including parasites
2. Consider empirical antibiotic therapy if symptoms persist beyond typical gastroenteritis timeline
3. Continue supportive care with IV fluids as needed
4. Symptomatic relief with loperamide if appropriate (noting caution in suspected infective diarrhoea)
5. Follow-up ultrasound scan in 4-6 weeks to ensure resolution of lymph node
6. Consider temporary cessation of Mounjaro until symptoms resolve
7. Discharge when clinically stable with appropriate safety-netting advice

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Refined clerking (2 days ago 20:49)

Refined clerking Sat 04 April 2026 20:49

Last Modified: 2 days ago

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Medical ST5 Miller Clerking
04/04/26 20:49

Presenting Complaint:
Left-sided abdominal pain

History of Presenting Complaint:
Presented with a 2-week history of feeling unwell following a presumed viral gastroenteritis. She reported nausea and feverish episodes at the time, managed at home with paracetamol and fluids. Since then, she has developed left-sided lower abdominal pain, with some urinary frequency. She also described breathlessness, pins and needles in the fingers and toes, and a recent episode of dizziness with difficulty walking in a straight line, which has since improved.

She saw a doctor on Monday and had a urine test and blood tests arranged. Blood results showed mildly abnormal liver function tests, including a raised alkaline phosphatase, with otherwise reassuring markers. There was concern regarding possible biliary pathology, although the pain is not typical for biliary colic as it is left-sided rather than right-sided and not clearly related to fatty meals.

No recent travel, tattoos, alcohol excess, recreational drug use, or antibiotic exposure. No new prescribed medications. She takes an immune booster supplement, Biocare Immune, which she says she can take with thyroxine.

Past Medical History:
• Turner syndrome
• Hypothyroidism
• Previous hysterectomy

Drug History:
• Thyroxine
• Citalopram
• Biocare Immune supplement

Allergy History:
NKDA

Social History:
Lives with her partner. She is a carer for her sister, who has Down syndrome. Her sister is currently staying with her father, so she has a week off. She is a non-smoker. No alcohol or illicit drug use.

On Examination:
General appearance: Comfortable and able to converse.
Observations:: Not recorded.
• Abdomen: Soft. Mild left-sided lower abdominal tenderness. No right upper quadrant tenderness. Murphy's sign negative. No guarding or peritonism.
• Cardiovascular: Normal peripheral pulses. No leg swelling.
• Respiratory: Breathless by history. Chest examination not reported as abnormal.

Investigations:
• Urine dip (Monday): Performed by GP; result not provided.
• Blood tests: Mildly elevated liver function tests, including alkaline phosphatase. Other markers for significant liver disease normal.

Impression:
Abnormal liver function tests with left-sided abdominal pain following recent viral illness.
Differential Diagnoses: Gallstones/choledocholithiasis, viral hepatitis or post-viral transaminitis.

Management Plan:
1. Arrange repeat liver function tests tomorrow.
2. Arrange viral hepatitis screen and EBV testing.
3. Request ultrasound scan of the liver and biliary tree.
4. No antibiotics indicated at present as there is no evidence of bacterial cholangitis.
5. Consider chest X-ray if breathlessness persists or if clinically indicated.
6. Discharge home if clinically well, with outpatient investigation arranged and return instructions discussed.

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Refined clerking (2 days ago 20:55)

Refined clerking Sat 04 April 2026 20:55

Last Modified: 2 days ago

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Medical ST5 Miller Clerking
04/04/26 20:55

Presenting Complaint:
Abdominal pain

History of Presenting Complaint:
Presented with left lower abdominal pain following a recent viral illness with nausea and feverish symptoms. She initially thought her symptoms were related to a sickness bug, which had been affecting her ability to walk around and function. Last weekend she developed pain on the left side of the lower abdomen, which prompted review by her GP on Monday. Urine testing was performed and bloods were requested. She was contacted today because of abnormal blood results.

Blood tests showed mildly deranged liver function tests and abnormal bone profile, with raised alkaline phosphatase felt to be of hepatic origin as other liver markers were also elevated. There was concern for possible biliary pathology, including gallstones or a stone in the bile duct, although the pain is not typical for this and is not right-sided or clearly post-prandial. Viral hepatitis or another viral illness causing liver inflammation was also discussed as a possibility.

She reported fever during the initial illness, with the last temperature about 2 weeks ago. She has also had cough, breathlessness, pins and needles in her fingers and toes, dizziness, and difficulty walking in a straight line. These symptoms have improved somewhat, but she still feels unwell, particularly on exertion. No recent travel, tattoos, illicit drug use, or antibiotic use. She has been managing at home with paracetamol and fluids. No change in bowel habit other than possibly more frequent motions and more frequent urination. No dysuria. No vaginal discharge. No right-sided pain or pain on deep inspiration.

Past Medical History:
• Turner syndrome
• Hypothyroidism
• Hysterectomy

Drug History:
• Levothyroxine
• Citalopram
• Biocare Immune supplement

Allergy History:
• NKDA

Social History:
Lives with partner and sister, whom she cares for. She is a carer. Her sister has Down syndrome. Smoking: non-smoker. Alcohol and illicit drugs: denies.

On Examination:
Alert and comfortable at rest.
Abdomen: Soft, mildly tender in the left lower quadrant. No right upper quadrant tenderness. No Murphy's sign. No guarding or peritonism.
Cardiovascular: No peripheral oedema.
Respiratory: Breathlessness reported, but chest examination not described as abnormal.

Investigations:
• LFTs: mildly elevated, with raised alkaline phosphatase and other liver markers also elevated
• Bone profile: abnormal secondary to raised alkaline phosphatase; calcium normal
• Urine dip: performed by GP

Impression:
Mild transaminitis with raised alkaline phosphatase, likely hepatic in origin.
Differential Diagnoses: Transient viral hepatitis; biliary obstruction/choledocholithiasis; gallstones.

Management Plan:
1. Repeat liver function tests tomorrow.
2. Arrange viral screen including hepatitis and EBV serology.
3. Arrange abdominal ultrasound scan to assess liver, gallbladder and biliary tree.
4. No antibiotics indicated at present as there is no evidence of bacterial cholangitis.
5. Consider chest X-ray if breathlessness persists or if clinically indicated.
6. Discharge home if well, with outpatient imaging and blood tests arranged, rather than admission overnight.

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Meeting (115 days ago 16:20)

Meeting Fri 12 December 2025 16:20

Last Modified: 115 days ago

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Summary of gastroenterology consultations held on 12th December 2025.

Multiple follow-up appointments were reviewed:

1. Female patient - Iron deficiency investigation: Recent blood tests showed Hb improvement from 113 to 120 g/L following iron supplementation. Ferritin increased from 37 to 70s, transferrin saturation was 7% pre-iron. Had normal OGD in March 2022 and colonoscopy in September 2022 with normal FIT. Plan: Stop iron supplementation and monitor Hb and ferritin levels. Follow-up if clear evidence of iron deficiency anaemia develops.

2. 38-year-old male with small bowel Crohn's disease: Plan to restart biologic therapy as previously agreed in November. Calprotectin 141. Follow-up in 6 months.

3. Vicky (MRN: 59481) - Post hemicolectomy: Experiencing watery diarrhoea since surgery with some ulceration at anastomosis. Previous low elastase but suspected dilutional. RUQ pain attributed to inflamed anastomosis. Plan: Blood tests during acute episodes, follow-up in 4 months.

4. Robert Beard (DOB: 03/2003) - Ulcerative colitis: Doing well on vedolizumab. Stable disease. Case noted for potential publication - unusual presentation of secukinumab-induced segmental colitis requiring sigmoid colectomy, later developing typical UC, now well controlled on upadacitinib.

5. Aaron Valko (MRN: 1180213) - Polyposis condition: Multiple sessile serrated adenomas from 2022. Awaiting colonoscopy, to be arranged.

6. Andrew (MRN: 135909013) - GP trainee in Gibraltar: Crohn's disease with mild-moderate changes in terminal ileum and caecum. Currently asymptomatic, not on treatment. Requires colonoscopy when returns to UK.

7. Emma Lewis (MRN: 663547) - Cyclical vomiting syndrome: Pain appears to predominate over vomiting. Recent acute presentation with severe pain. Gynaecological involvement with haemorrhagic cyst noted on USS. Started on medical management. Follow-up arranged.

8. Justin - Fisherman from Brixham: Initially investigated for possible IBD, ultimately diagnosed with terminal ileal cancer. Now under oncology follow-up. Some chronic inflammation noted in resection specimen but felt secondary to malignancy rather than Crohn's disease.

9. Robin - Crohn's disease: On infliximab and azathioprine, bowel movements stable. Previous MRI showed mild stricturing disease. Plan for restaging colonoscopy and fecal calprotectin.

10. Victoria Gray (MRN: 744166) - Hypersalivation and IBS symptoms: Care home owner under significant stress. Upper GI symptoms being investigated. Given IBS management advice.

11. Leo Newman (MRN: 766465) - 21-year-old with mixed upper and lower GI symptoms: Initially reluctant for endoscopy due to anxiety. Subsequently attended hot clinic due to worsening symptoms. Endoscopy arranged for 20th December 2025.

12. Anne Evans (MRN: 541539) - Post celiac artery stenting: Recurrent upper abdominal pain after eating. Previous stenting at Derriford in 2024 with initial improvement, symptoms recurred. Plan: CT imaging to assess stent patency, referral back to Derriford IR if indicated.

13. Mr Sutton - 61-year-old: Incidental finding of terminal ileitis with 6 ulcers on screening colonoscopy. Asymptomatic. Plan: Fecal calprotectin initially, colonoscopy if elevated to obtain tissue diagnosis.

14. Various other patients discussed including those with constipation, post-infectious IBS, anastomotic strictures, and complex symptom constellations.

General themes: Several cases of iron deficiency investigation, multiple IBD follow-ups with good disease control, and complex diagnostic challenges requiring multidisciplinary input.

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Refined clerking (2 days ago 21:02)

Refined clerking Sat 04 April 2026 21:02

Last Modified: 2 days ago

MRN:

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Medical ST5 Miller Clerking
04/04/26 21:02

Presenting Complaint:
Left lower abdominal pain

History of Presenting Complaint:
Presented with a recent viral illness, described as a sickness bug, associated with nausea and fever/temperatures around 2 weeks ago. She remained at home, rested in bed, and took paracetamol and fluids. Since then she has felt generally unwell, with reduced sleep and some shortness of breath. Over the last weekend she developed pain down the left side, mainly in the left lower abdomen. She initially wondered if this was related to the recent infection but sought medical review due to persistence.

She saw her GP on Monday, had a urine test and was asked to have blood tests. Results showed mildly abnormal liver function tests. She reports intermittent fever only during the recent viral illness, with no recent travel, tattoos, alcohol excess, or illicit drug use. No new prescribed medications; she has been taking Biocare Immune supplement. She also reports pins and needles in her fingers and toes and a brief episode of dizziness with difficulty walking in a straight line, which has since improved. No cough or coryzal symptoms. Bowels are normal, with a normal stool this morning. Urinary frequency is slightly increased but urine otherwise normal. No vaginal discharge.

Past Medical History:
• Hypothyroidism
• Turner syndrome
• Hysterectomy

Drug History:
• Levothyroxine
• Citalopram
• Biocare Immune supplement

Allergy History:
• No known drug allergies

Social History:
Lives with partner.  
Cares for her sister, who has Down syndrome.  
Smoking: non-smoker.  
Alcohol: denies recent alcohol use.  
Illicit drugs: denies.  
Functional status affected recently by feeling unwell and difficulty walking around.

On Examination:
General appearance: Alert and well enough for discharge.  
Abdomen: Soft, tender in the left lower abdomen. No guarding. No right upper quadrant tenderness. Murphy’s sign negative. No abdominal findings to suggest cholecystitis.  
Cardiovascular: Heart sounds heard, no abnormalities reported. Peripheral pulses present.  
Respiratory: Breathlessness reported, chest examination not reported as abnormal.  
Neurological: Brief dizziness and pins and needles reported, no persistent focal deficit described.

Investigations:
• Liver function tests: Mildly elevated, with raised ALP and other liver enzymes; pattern felt more consistent with hepatobiliary source than bone source
• Bone profile: ALP abnormal, calcium normal
• Urine test (GP): Done prior to referral, result not stated

Impression:
Mild transaminitis / cholestatic liver biochemistry following recent viral illness.  
Differential Diagnoses: Gallstones / choledocholithiasis, viral hepatitis, post-viral hepatitis.

Management Plan:
1. Discharge home as clinically well.
2. Arrange repeat liver function tests tomorrow.
3. Arrange viral hepatitis screen, including hepatitis B and EBV.
4. Arrange abdominal ultrasound scan tomorrow to assess gallbladder and bile ducts.
5. No antibiotics indicated; no evidence of bacterial cholangitis.
6. Consider chest X-ray if breathlessness persists or if clinically indicated.

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Refined ultra rapid review (64 days ago 23:23)

Refined ultra rapid review Sun 01 February 2026 23:23

Last Modified: 64 days ago

MRN:

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Medical ST5 Miller Review
23:00

Developing hypotension, presyncope on standing.

Review of previous notes:

Examination:
Chest examination normal. Patient febrile and hypotensive, responding to fluid resuscitation.

Investigations:
TnT 150 - vehemently denies chest pain at any time since admission recently but is an unclear historian. With concom

Impression:
Continued diagnostic uncertainty but biliary infection with delirium seems most likely
Raised TnT - most likely T2MI secondary to infection given lack of chest pain, I think that the cardiology team would not intervene in the absence of chest pain
CT scan shows pancreatic inflammation possibly consistent with stone passage, but no clear ductal dilatation. Blood tests compatible with biliary infection.

Plan:
1. IV fluids stat
2. Paracetamol
3. Continue Tazocin (dose due now)
4. Flag to night registrar
5. VBG and TnT repeat
6. Aspirin 300mg PO stat - clopidogrel considered but potential for biliary intervention needs to be balanced with this. I think that MI with obstructed coronaries without chest pain seems very unlikely so I don't think there is a role for DAPT now.

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Refined clerking (2 days ago 21:07)

Refined clerking Sat 04 April 2026 21:07

Last Modified: 2 days ago

MRN:

Content:

Medical ST5 Miller Clerking
04/04/2026 21:07

Presenting Complaint:
Abdominal pain

History of Presenting Complaint:
Presented with left lower abdominal pain following a recent viral-type illness. She had been unwell with nausea and feverish symptoms around 2 weeks ago, after which the abdominal pain developed. She reported associated breathlessness, cough, pins and needles in the fingers and toes, and dizziness with an episode of difficulty walking in a straight line. Symptoms were worse when up and about and less noticeable when lying down. She denied right upper quadrant pain, pain worsened by fatty meals, jaundice, change in bowel habit, dysuria, vaginal discharge, recent travel, tattoos, alcohol excess, smoking or illicit drug use.

She is a carer for her sister, who has Down syndrome, and has been struggling to mobilise because of feeling unwell. She has a partner at home and her sister is currently staying with her father, so she has the week off.

She was seen by a doctor on Monday, when a urine test was done and blood tests were requested. Blood results were reviewed today and showed mildly abnormal liver tests and bone profile, prompting assessment.

Past Medical History:
• Turner syndrome
• Hypothyroidism
• Hysterectomy

Drug History:
• Levothyroxine
• Citalopram
• Biocare Immune supplement

Allergy History:
• No known drug allergies

Social History:
Partner at home. Carer for sister with Down syndrome. Smoking: non-smoker. Alcohol: denies. Recreational drugs: denies.

On Examination:
Alert and not acutely unwell.
Observations: not documented.
• Abdomen: Soft. Mild left-sided lower abdominal tenderness. No right upper quadrant tenderness. No peritonism. Murphy's sign negative.
• Cardiovascular: Normal peripheral pulses. No leg swelling.
• Respiratory: Breathless by history. Chest examination not documented.
• Neurological: No focal deficit elicited on brief assessment.

Investigations:
• Liver function tests: Mildly elevated transaminases and cholestatic enzymes, with raised alkaline phosphatase.
• Bone profile: Abnormal due to alkaline phosphatase, with normal calcium.
• Urine dipstick: Performed by GP.

Impression:
Mild transaminitis with raised alkaline phosphatase following recent viral illness. Differential diagnoses: transient viral hepatitis, biliary obstruction/choledocholithiasis, gallstones.

Management Plan:
1. Repeat liver function tests tomorrow.
2. Arrange viral hepatitis/EBV screen.
3. Arrange urgent abdominal ultrasound to assess the liver and biliary tree.
4. No antibiotics indicated at present as there is no evidence of bacterial cholangitis.
5. Consider chest X-ray if breathlessness persists or if initial investigations do not explain symptoms.
6. Discharge if well, with outpatient follow-up for investigations and results.

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Refined clerking (137 days ago 22:50)

Refined clerking Thu 20 November 2025 22:50

Last Modified: 137 days ago

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Medical ST5 Miller Clerking

Presenting Complaint:
Ulcerative colitis flare

History of Presenting Complaint:
Patient with known ulcerative colitis admitted with worsening symptoms following failed infliximab infusion. Had been receiving infliximab treatment but developed severe allergic reaction during recent infusion with facial swelling, throat tightness, and shortness of breath requiring emergency treatment. Since discontinuing infliximab and reducing prednisolone dose, symptoms have progressively worsened over past 2 days.

Currently experiencing increased bowel frequency (7 times daily) with loose, watery stools but no blood. Experiencing lower abdominal pain described as similar to previous flares but less severe. Reports hot flushes and night sweats since hospital admission. Also experiencing frequent nosebleeds and facial lesion with purulent discharge for past week.

Past Medical History:
• Ulcerative colitis - recent diagnosis with aggressive disease pattern
• Anaemia secondary to IBD
• Infliximab allergy - severe reaction with facial swelling and respiratory symptoms

Drug History:
• Prednisolone 35mg PO OD (reducing - due to decrease to 30mg tomorrow)
• Omeprazole 20mg PO BD
• Mesalazine tablets PO
• Cholecalciferol (Vitamin D3)
• Topical treatment for perianal irritation (improving)

Recently Stopped Medications:
• Infliximab - stopped due to severe allergic reaction

Allergy History:
• Infliximab - severe allergic reaction (facial swelling, throat tightness, shortness of breath)

Social History:
Living situation not specified
Mobility independent
No carers mentioned
Occupation not specified
Smoking status not mentioned
Alcohol history not mentioned
Functional Status: Disease impacting quality of life with frequent hospital admissions

On Examination:
General Appearance: Alert, appears well but concerned about recurrent symptoms
Observations: Temperature 37.2°C, other observations not specified
• Abdomen: Tender in lower abdomen, particularly left lower quadrant. No peritonism
• Cardiovascular: Not examined
• Respiratory: Not examined
• Neurological: Not examined
• Other: Facial lesion on cheek with small punctum and underlying induration, evidence of purulent discharge. No other skin lesions noted

Investigations:
• CRP: 136 mg/L (elevated, previously 100+ on admission, had reduced to 80 but now rising again)
• Temperature: 37.2°C
• COVID test: Negative

Impression:
Ulcerative colitis flare following discontinuation of infliximab due to severe allergic reaction
Differential Diagnoses: Possible underlying infection given raised inflammatory markers
Secondary issues: Steroid side effects including facial skin infection, nosebleeds, and constitutional symptoms

Management Plan:
1. Admit for IV steroid therapy to induce remission quickly
2. Monitor inflammatory markers and clinical response to treatment
3. Continue PPI cover while on high-dose steroids
4. Dermatology review of facial lesion if not improving
5. Discuss alternative biologic therapies with IBD team for December 8th appointment
6. Patient education regarding realistic timeframes for alternative treatments
7. Gastroenterology bed
8. Escalation plan to be discussed - likely appropriate for all active treatments given young age and new diagnosis

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Refined clerking (2 days ago 21:08)

Refined clerking Sat 04 April 2026 21:08

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Medical ST5 Miller Clerking
04/04/2026 21:08

Presenting Complaint:
Left-sided abdominal pain

History of Presenting Complaint:
Patient recently had a vomiting and febrile illness approximately 2 to 3 weeks ago, which settled with rest, fluids and paracetamol. Since then, she has remained generally unwell with poor sleep and ongoing breathlessness. Over the last weekend she developed pain in the left lower abdomen/left flank. She was reviewed by a doctor on Monday and had a urine dip and blood tests arranged. Blood results today showed mildly elevated liver function tests and abnormal bone profile with normal calcium. She also reports pins and needles in the fingers and toes, and an episode of dizziness with difficulty walking in a straight line a few days ago, which has improved. No recent travel, tattoos, alcohol misuse or illicit drug use. No recent medication changes apart from starting Biocare Immune supplement. No right upper quadrant pain, no postprandial fatty food-related pain, and no history of known gallstones. No persistent fever over the last few days. No bowel or urinary symptoms of concern, although she may be passing urine more frequently.

Past Medical History:
• Hypothyroidism
• Turner syndrome
• Previous hysterectomy

Drug History:
• Levothyroxine
• Citalopram
• Biocare Immune supplement

Allergy History:
• No known drug allergies

Social History:
Lives with partner and sister for whom she is a carer. Sister has Down syndrome. She is a non-smoker. No illicit drug use. No recent alcohol excess. Functional capacity currently reduced by feeling unwell and breathless.

On Examination:
Alert and clinically stable.
Cardiovascular: Heart sounds normal. Peripheral pulses present.
Respiratory: Chest clear on auscultation.
Abdomen: Soft. Mild tenderness in the left lower abdomen. No right upper quadrant tenderness. No guarding or peritonism. Murphy's sign negative.
Neurological: No focal deficit on brief assessment.
Other: No leg swelling.

Investigations:
• Liver function tests: Mildly elevated.
• Bone profile: Abnormal due to elevated alkaline phosphatase; calcium normal.
• Other liver blood tests: No evidence of significant liver failure or bacterial cholangitis.
• Urine test: Performed by GP prior to attendance.

Impression:
Mild transaminitis with elevated alkaline phosphatase, likely post-infective or hepatobiliary in origin.  
Differential Diagnoses: Gallstones/choledocholithiasis, viral hepatitis, post-viral inflammatory change.

Management Plan:
1. Arrange repeat liver function tests and bloods for viral hepatitis/EBV screen.
2. Request abdominal ultrasound to assess for gallstones or biliary obstruction.
3. No antibiotics indicated at present as there is no evidence of bacterial cholangitis.
4. Consider chest X-ray if breathlessness persists or if initial work-up is unrevealing.
5. Discharge home if clinically well, with outpatient follow-up for ultrasound and repeat bloods.

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Endoscopy report (129 days ago 14:26)

Endoscopy report Fri 28 November 2025 14:26

Last Modified: 129 days ago

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Indication:
Dysphagia and weight loss. Patient reports difficulty swallowing requiring her to lean to one side to help food go down. Food occasionally gets stuck in the oesophagus. Associated anxiety and reduced oral intake leading to rapid weight loss. Also has concerns about bowel function with colorectal appointment scheduled for next Tuesday.

Findings:
[Endoscopic procedure commenced but findings not documented in this transcription - procedure was in preparation phase only]

Plan:
Upper GI endoscopy (OGD) performed with throat spray anaesthesia (patient declined sedation initially but agreed to have sedation available if needed). Duodenal biopsies to be taken to exclude coeliac disease as cause of weight loss. Follow-up with colorectal team scheduled for next Tuesday regarding bowel symptoms.

Histology:
Duodenal biopsies planned for coeliac screen (specific pot details not documented in this pre-procedure transcription)

Breakdown of Findings:
[Procedure was in preparation phase at time of transcription - endoscopic findings not yet available]

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Clinic letter (104 days ago 15:29)

Clinic letter Tue 23 December 2025 15:29

Last Modified: 104 days ago

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Diagnosis:
Iron deficiency with rectal bleeding - ?colorectal malignancy

Other Medical Diagnoses
• L4/L5 spinal stenosis with chronic back pain
• Cervical spine decompression required
• Psoriasis
• Reduced mobility requiring walking stick

Medications:
• Sachets for constipation (unspecified laxative preparation)
• Spinal injections for stenosis

Investigations:
• FBC: Low iron levels without anaemia
• Faecal occult blood test: Positive for blood
• CT scan cervical spine: Awaiting

Plan:
1. Upper GI endoscopy today to investigate iron deficiency
2. PR examination today to assess rectum given bleeding history
3. CT colonography with contrast (patient declined colonoscopy due to mobility issues)
4. Follow-up results and plan further management

Dear Doctor,

Thank you for referring this patient with iron deficiency and positive faecal occult blood testing. The patient has a background of significant spinal stenosis affecting L4/L5 with reduced mobility requiring walking aid, and is awaiting cervical spine decompression.

The patient reported previous constipation-related pain which has improved with laxative sachets. Given the iron deficiency with positive faecal blood, we discussed investigation options to exclude colorectal malignancy. Due to mobility limitations, the patient declined colonoscopy and we have arranged CT colonography as an alternative.

I performed upper GI endoscopy today with consent, explaining the risks of bleeding and perforation (both <1 in 9000). A PR examination was also conducted given the bleeding history. The patient was accompanied by their daughter.

We will arrange CT colonography and follow up the results. I will write again once investigations are complete.

Yours sincerely,
Consultant Gastroenterologist

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Refined clerking (40 days ago 19:02)

Refined clerking Wed 25 February 2026 19:02

Last Modified: 40 days ago

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Medical ST5 Miller Clerking

Date/Time: 26/02/2025, 19:02

Presenting Complaint:
Acute breathlessness

History of Presenting Complaint:
Colin Penn is an 88-year-old gentleman who presented to Torbay Hospital A&E with acute breathlessness. Collateral history obtained from paramedics and his son (Robert Penn, contacted by telephone) indicates he has been feeling generally unwell for the approximately 10 days prior to presentation. He lives alone in an assisted living apartment complex in the Torquay area. His son lives in North Devon and has had only intermittent telephone contact; he was not aware of any acute deterioration prior to this admission. No further collateral history was available from individuals who may have seen him more recently.

On presentation, he was hypoxic with saturations of 85% on air, requiring escalation to high-flow nasal oxygen (Optiflow) at FiO2 90% and 50L/min flow to achieve saturations of 90-92%. He was noted to be drowsy with a dry tongue. Bilateral pitting oedema to the hips was present. Respiratory examination demonstrated expiratory polyphonic wheeze throughout with coarse crepitations to the mid zones bilaterally, consistent with pulmonary oedema. ECG demonstrated atrial fibrillation with PVCs and biphasic T-waves in V5 and V6, without clear evidence of acute ischaemia on repeat tracing. Biochemistry revealed a metabolic acidosis with an elevated lactate, hyponatraemia, hypocalcaemia, elevated ALP and bilirubin above his established Gilbert's syndrome baseline, and a rise in neutrophils and white cell count. Troponin T was 24, though the sample was haemolysed and is difficult to interpret in isolation. The clinical picture and ECG changes are felt to be consistent with a missed myocardial infarction approximately 10 days ago, with subsequent acute decompensated heart failure. Further furosemide and salbutamol have been prescribed.

Past Medical History:
• Atrial fibrillation
• Hypertension
• Chronic kidney disease, stage 3
• Gout
• Gilbert's syndrome
• Asbestos-induced pleural plaques and pulmonary fibrosis
• Hydronephrosis secondary to renal calculus obstruction (July 2024) — managed with nephrostomy
• Cholecystectomy (date unknown)
• Cataracts — recent lens implant (date unknown)
• Bereavement — death of spouse (March 2025)

Drug History:
• Tiolaz Duo eye drops 1 drop to both eyes QDS
• Allopurinol 100mg PO OD
• Rivaroxaban 15mg PO OD
• Doxazosin 2mg PO ON
• Amlodipine 10mg PO OD
• Bisoprolol 5mg PO OD

Recently Stopped Medications:
• None known

Allergy History:
• Unknown — not documented during this clerking

Social History:
Living situation: Lives alone in an assisted living apartment complex in the Torquay area.
Mobility: Reported to walk a couple of times per day. Does not drive (Land Rover observed in belongings but confirmed not driven by patient).
Carers: No formal carers documented. Lives independently. Son (Robert Penn) lives in North Devon; limited recent contact.
Occupation: Retired.
Smoking: Ex-smoker — stopped approximately 7 years ago. Pack-year history not documented.
Alcohol: Not documented.
Functional Status: Previously independent with activities of daily living based on collateral history.

On Examination:
General Appearance: Elderly gentleman, visibly uncomfortable and drowsy. Mask in situ for oxygen delivery.
Observations: HR 66 bpm | BP 101/53 mmHg | RR 26 breaths/min | O2 sats 92% on Optiflow (FiO2 90%, 50L/min) — initially 85% on air at commencement of review
• Cardiovascular: Low-volume regular peripheral pulses. Bilateral pitting oedema to the hips. Heart rate 66 bpm.
• Respiratory: Expiratory polyphonic wheeze throughout. Coarse crepitations to the mid zones bilaterally. RR 26 breaths/min.
• Other: Dry tongue. No further systems formally documented at time of clerking.

Investigations:
• Arterial Blood Gas — on presentation (26/02/2025): pH 7.42, pCO2 3.7, pO2 7.2, Base Excess -5
• Arterial Blood Gas — subsequent (26/02/2025): pH 7.28, pCO2 4.3, pO2 7.5 on 15L O2, Base Excess -10.6, Lactate 4.8, O2 sats 86.3% on gas
• Haemoglobin (26/02/2025): 120 — anaemic since at least December 2024; normal haemoglobin in August 2024
• Platelets (26/02/2025): 221
• Neutrophils (26/02/2025): 9.98 (previously 5.12)
• White Cell Count (26/02/2025): 11.2 (previously 7.2)
• MCV: Normocytic
• Troponin T (26/02/2025): 24 — haemolysed sample, interpret with caution
• Sodium (26/02/2025): 126
• Calcium (26/02/2025): 1.06
• Glucose (26/02/2025): 11.1
• Creatinine (26/02/2025): 113 — at patient's baseline
• Urea (26/02/2025): 9.2
• ALP (26/02/2025): 136 (previously 118)
• Bilirubin (26/02/2025): 68 (baseline 30 — above Gilbert's syndrome baseline)
• ALT (26/02/2025): 112
• CRP (26/02/2025): 6 — no previous CRP on record
• Electrolytes (26/02/2025): Otherwise normal
• MRSA swab (26/02/2025): Negative
• ECG (26/02/2025): Atrial fibrillation with PVCs. QTc 464ms. Biphasic T-waves in V5 and V6. No clear evidence of acute ischaemia. Stable on repeat tracing.
• Chest X-Ray (26/02/2025): Bilateral calcified pleural plaques consistent with asbestos exposure. New bilateral pleural effusions with fluid along the right horizontal fissure. Airspace consolidation in the right middle zone and both lower zones. Enlarged cardiac silhouette. Appearances suggestive of pulmonary oedema; coexisting infective process cannot be excluded.

Impression:
Acute decompensated heart failure, likely secondary to missed myocardial infarction approximately 10 days prior to presentation.
Differential Diagnoses: Coexisting lower respiratory tract infection/pneumonia cannot be excluded given consolidation on CXR and raised white cell count.
Secondary Issues: Metabolic acidosis with elevated lactate suggesting end-organ hypoperfusion. Hyponatraemia. Hypocalcaemia. Haemolysed troponin — repeat required on non-haemolysed sample. Pre-existing asbestos-induced pleural plaques and pulmonary fibrosis may confound respiratory picture. AF with PVCs and prolonged QTc on background of bisoprolol use. CKD stage 3 — caution with diuresis and nephrotoxic agents. Recent bereavement.

Management Plan:
1. Continuous monitoring — cardiac monitoring, hourly observations, strict fluid balance and urine output monitoring.
2. Repeat Troponin T on non-haemolysed sample with serial ECGs to further evaluate for myocardial infarction. Consider cardiology review.
3. Maintain Optiflow high-flow nasal oxygen (FiO2 90%, 50L/min) — titrate to maintain saturations ≥94%. Further IV furosemide for diuresis. Further salbutamol nebulisers prescribed for bronchospasm.
4. Correct electrolyte abnormalities — hyponatraemia and hypocalcaemia to be addressed with appropriate replacement and ongoing monitoring.
5. Bloods to be repeated including repeat ABG, renal function and electrolytes following diuresis.
6. Cardiology review — given likely missed MI with acute decompensated heart failure and new ECG changes.
7. Admission to a Cardiology or Acute Medical bed for ongoing monitoring and management.
8. Escalation plan — to be discussed with patient when clinical condition permits and with next of kin (son, Robert Penn — contact number obtained). Suitability for CPR, ITU and NIV to be formally documented. Patient's wishes and goals of care to be established given age, comorbidities and acuity of presentation.

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Investigations:

Arterial Blood Gas on presentation (26/02/2025): pH 7.42, pCO2 3.7, pO2 7.2, Base Excess -5. Arterial Blood Gas subsequent (26/02/2025): pH 7.28, pCO2 4.3, pO2 7.5 on 15L O2, Base Excess -10.6, Lactate 4.8, O2 sats 86.3%. Haemoglobin (26/02/2025): 120 (anaemic since at least December 2024; normal August 2024). Platelets (26/02/2025): 221. Neutrophils (26/02/2025): 9.98 (previously 5.12). White Cell Count (26/02/2025): 11.2 (previously 7.2). MCV: Normocytic. Troponin T (26/02/2025): 24 — haemolysed sample. Sodium (26/02/2025): 126. Calcium (26/02/2025): 1.06. Glucose (26/02/2025): 11.1. Creatinine (26/02/2025): 113 (at baseline). Urea (26/02/2025): 9.2. ALP (26/02/2025): 136 (previously 118). Bilirubin (26/02/2025): 68 (baseline 30). ALT (26/02/2025): 112. CRP (26/02/2025): 6. Electrolytes (26/02/2025): Otherwise normal. MRSA swab (26/02/2025): Negative. ECG (26/02/2025): Atrial fibrillation with PVCs, QTc 464ms, biphasic T-waves in V5 and V6, no clear acute ischaemia, stable on repeat. Chest X-Ray (26/02/2025): Bilateral calcified pleural plaques, new bilateral pleural effusions with fluid along right horizontal fissure, airspace consolidation right middle zone and both lower zones, enlarged cardiac silhouette — appearances consistent with pulmonary oedema, coexisting infection possible.

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Refined clerking (40 days ago 19:05)

Refined clerking Wed 25 February 2026 19:05

Last Modified: 40 days ago

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Content:

Medical ST5 Miller Clerking
Date/Time: 26/02/25 19:05

Presenting Complaint:
Acute breathlessness

History of Presenting Complaint:
An 88-year-old male presented to the Emergency Department at Torbay Hospital with acute breathlessness. Collateral history obtained from paramedics and from his son (Robert Penn, reachable by phone, based in North Devon) indicates he has been feeling generally unwell for the last 10 days prior to presentation.

On presentation he was hypoxic, requiring high-flow oxygen via Optiflow. He was too unwell and fatigued to provide a detailed history himself. His son confirmed that when last spoken to by phone (date unclear), he had appeared well. He was not known to have deteriorated recently by any close contact, as he lives alone and has limited social contact.

ECG on arrival demonstrated atrial fibrillation with PVCs and biphasic T-waves in V5 and V6, raising concern for a missed myocardial infarction approximately 10 days prior, felt to be the likely precipitant of acute decompensated heart failure. Troponin T was 24, though this result was from a haemolysed sample and is therefore difficult to interpret reliably. Chest X-ray confirmed new bilateral pleural effusions with airspace consolidation and an enlarged cardiac silhouette consistent with pulmonary oedema.

During assessment, the patient was noted to be increasingly drowsy with high oxygen requirements, prompting urgent escalation of respiratory support and further diuresis. His son was contacted and updated on the clinical situation; he was informed that the patient is in a resuscitation bay in the Emergency Department and will be transferred to a ward shortly. He expressed willingness to visit and consented to further contact if clinically required.

Past Medical History:
• Hydronephrosis secondary to renal calculus obstruction (July 2024), leading to nephrostomy
• Asbestos-induced pleural plaques
• Pulmonary fibrosis (asbestos-related)
• Chronic kidney disease stage 3
• Gout
• Atrial fibrillation
• Gilbert's syndrome
• Hypertension
• Cholecystectomy (date unknown)
• Cataracts — recent surgical treatment (lens insertion, date not specified)
• Bereavement — death of spouse (March 2025)

Drug History:
• Theloz Duo eye drops 1 drop to both eyes QDS
• Allopurinol 100mg PO OD
• Rivaroxaban 15mg PO OD
• Doxazosin 2mg PO ON
• Amlodipine 10mg PO OD
• Bisoprolol 5mg PO OD

Recently Stopped Medications:
• None documented

Allergy History:
• Not documented — to be clarified

Social History:
Living situation: Lives alone in an apartment (sheltered/assisted-living complex — nature of support at complex not fully established; staff at the complex to be contacted for further collateral).
Mobility: Walks independently a couple of times daily. Does not drive (Land Rover noted in belongings but not driven by patient).
Carers: No formal or informal carers documented. Son (Robert Penn) lives in North Devon.
Occupation: Retired.
Smoking: Ex-smoker — stopped approximately 7 years ago.
Alcohol: Not documented.
Functional Status: Largely independent prior to this admission based on available collateral.

On Examination:
General Appearance: Elderly male, visibly uncomfortable and breathless, drowsy, wearing high-flow oxygen mask.
Observations: HR 66 bpm, BP 101/53 mmHg, RR 26-28 breaths/min, O2 saturations 85% on initial review (improved to 90% on air; 92% on Optiflow 90% FiO2 at 50 L/min), temperature not documented.
• Cardiovascular: Low-volume regular peripheral pulses. Pitting oedema to the hips bilaterally.
• Respiratory: Polyphonic expiratory wheeze throughout. Coarse crepitations to the mid zones bilaterally.
• Other: Dry tongue.

Investigations:
• Arterial Blood Gas on presentation: pH 7.42, pCO2 3.7, pO2 7.2, base excess -5
• Arterial Blood Gas (repeat): pH 7.28, pCO2 4.3, pO2 7.5 (on 15 L/min oxygen), base excess -10.6, O2 saturations 86.3%
• Sodium: 126
• Calcium: 1.06
• Glucose: 11.1
• Lactate: 4.8
• Haemoglobin: 120 (normocytic; anaemia noted since at least December 2024; normal in August 2024)
• Platelets: 221
• Neutrophils: 9.98 (previously 5.12)
• White cell count: 11.2 (previously 7.2)
• Troponin T: 24 (haemolysed sample — interpret with caution)
• Creatinine: 113 (at patient's baseline)
• Urea: 9.2
• ALP: 136 (previously 118)
• ALT: 112
• Bilirubin: 68 (baseline 30 — in keeping with known Gilbert's syndrome)
• CRP: 6 (no previous result for comparison)
• Electrolytes: Normal
• MRSA swab: Negative
• Chest X-ray: Bilateral calcified pleural plaques consistent with known asbestos exposure. New bilateral pleural effusions with fluid along the right horizontal fissure. Airspace consolidation in the right middle zone and both lower zones. Enlarged cardiac silhouette. Appearances consistent with pulmonary oedema; coexisting infection possible.
• 12-lead ECG: Atrial fibrillation with PVCs. QTc 464ms. Biphasic T-waves in V5 and V6 (stable on repeat ECG). No definitive evidence of acute ischaemia.

Impression:
Acute decompensated heart failure, likely precipitated by a missed myocardial infarction approximately 10 days prior to presentation.
Differential Diagnoses: Community-acquired pneumonia (consolidation on CXR and raised WCC); mixed aetiology (pulmonary oedema with superimposed infection).
Secondary issues: Background asbestos-related pulmonary fibrosis and pleural plaques complicating respiratory assessment; CKD stage 3 relevant to diuretic dosing; haemolysed troponin limiting interpretation of ischaemic injury; hyponatraemia (Na 126) and hypocalcaemia (Ca 1.06) requiring monitoring; metabolic acidosis with raised lactate and low base excess on repeat ABG indicating physiological deterioration.

Management Plan:
1. Continuous monitoring: cardiac monitoring, hourly observations, fluid balance chart, and repeat ABG to assess response to treatment.
2. Further investigations: Repeat troponin T from non-haemolysed sample to clarify ischaemic injury; repeat electrolytes, renal function, and calcium; echocardiogram to assess left ventricular function; sputum culture if productive cough; blood cultures given consolidation and raised WCC.
3. Respiratory support: Optiflow high-flow nasal oxygen continued at 90% FiO2 and 50 L/min flow; titrate to maintain saturations ≥94% (Scale 2 in use).
4. Treatment: Further furosemide administered for acute decompensated heart failure with fluid overload. Salbutamol prescribed for polyphonic wheeze. Ongoing management of hyponatraemia and hypocalcaemia. Consider antibiotic therapy if infective cause confirmed or clinically deteriorating.
5. Cardiology input: Consider discussion with cardiology regarding likely missed NSTEMI, anticoagulation status (currently on rivaroxaban for AF), and further management of acute heart failure.
6. Social: Next of kin (son, Robert Penn) contacted and updated. Staff at patient's sheltered accommodation to be contacted for further collateral history and to establish support package on discharge. Adult social care referral to be considered.
7. Admission: Cardiology or acute medical ward bed; currently in resuscitation bay in the Emergency Department pending transfer.
8. Escalation plan: To be discussed formally with patient (when capacity allows) and with next of kin (Robert Penn). Given age, significant comorbidities, and degree of physiological compromise, suitability for CPR, ITU-level care, and NIV must be clarified urgently.

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Investigations:

Arterial Blood Gas on presentation: pH 7.42, pCO2 3.7, pO2 7.2, base excess -5. Arterial Blood Gas (repeat, on 15 L/min oxygen): pH 7.28, pCO2 4.3, pO2 7.5, base excess -10.6, O2 saturations 86.3%. Sodium: 126. Calcium: 1.06. Glucose: 11.1. Lactate: 4.8. Haemoglobin: 120 (normocytic; anaemia since at least December 2024; normal August 2024). Platelets: 221. Neutrophils: 9.98 (previously 5.12). White cell count: 11.2 (previously 7.2). Troponin T: 24 (haemolysed — interpret with caution). Creatinine: 113 (at baseline). Urea: 9.2. ALP: 136 (previously 118). ALT: 112. Bilirubin: 68 (baseline 30, in keeping with Gilbert's syndrome). CRP: 6. Electrolytes: Normal. MRSA swab: Negative. Chest X-ray: Bilateral calcified pleural plaques (asbestos exposure). New bilateral pleural effusions with fluid along the right horizontal fissure. Airspace consolidation in the right middle zone and both lower zones. Enlarged cardiac silhouette. Appearances consistent with pulmonary oedema; coexisting infection possible. 12-lead ECG: Atrial fibrillation with PVCs. QTc 464ms. Biphasic T-waves in V5 and V6 (stable on repeat ECG). No definitive acute ischaemia.

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Refined clerking (5 days ago 10:05)

Refined clerking Wed 01 April 2026 10:05

Last Modified: 5 days ago

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Content:

Presenting Complaint:
Worsening weakness

History of Presenting Complaint:
Presented with a subjective deterioration in mobility and weakness overnight, on a background of an acute lacunar stroke in the basal ganglia in August with residual left-sided weakness, particularly affecting the leg and hand. He reported that he had been improving with rehabilitation and had been able to walk, type, and play piano exercises with his left hand, but over the past few days had felt generally unwell and a little more wobbly. This morning he woke with marked difficulty standing and walking, and felt weaker on both sides, which felt different from his previous stroke symptoms. He denied new speech disturbance, new visual loss, or focal arm weakness. He described mild coryzal symptoms with cough, sputum, and feeling snotty. He also reported urinary frequency/dribbling over the past few days. Home blood glucose this morning was 15 mmol/L and on arrival was approximately 16 to 17 mmol/L. He felt his symptoms were similar to previous episodes when he had infection-associated hyperglycaemia.

Past Medical History:
• Acute lacunar stroke, August 2025, with residual left-sided weakness
• Diabetes mellitus, likely insulin-dependent
• Diabetic eye disease/macular changes
• Cataracts
• Sepsis with renal/urinary source, 2018
• Previous groin/abdominal cyst excision

Drug History:
• Insulin degludec (Tresiba) 38 units SC OD
• Dapagliflozin 10mg PO OD
• Clopidogrel 75mg PO OD
• Metformin PO
• Statin PO nocte

Allergy History:
NKDA

Social History:
Lives in Darlington.
Never smoker.
Minimal alcohol intake.
Previously taught data science to master's students at Exeter University.
Functionally independent but with residual stroke-related left-sided weakness; mobilising better prior to this episode.

On Examination:
Alert and able to give a coherent history.
Neurological: Speech normal. Upper limb power and hand grip symmetric on examination. Able to raise arms against resistance. Gait not formally assessed in detail, but observed walking into the room. No new focal upper limb deficit elicited.
Cardiovascular: Normal on brief examination.
Respiratory: No respiratory distress noted. Mild upper respiratory tract symptoms by history.
Abdomen: Soft and non-tender.

Investigations:
• Blood glucose: 16 to 17 mmol/L
• Urinalysis: to be sent for dipstick and laboratory testing
• Viral screen: requested
• Chest X-ray: requested
• Blood tests: requested

Impression:
Exacerbation of old stroke symptoms in the context of intercurrent illness and hyperglycaemia, most likely viral respiratory tract infection. 
No evidence from the history or examination of a new acute stroke.

Management Plan:
1. Check urinalysis and send urine for laboratory testing.
2. Send blood tests including infection screen.
3. Request viral screen.
4. Arrange chest X-ray to assess for chest infection.
5. Give insulin to reduce hyperglycaemia.
6. Review results and reassess clinically for alternative causes of symptom exacerbation.

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Summary:

Investigations:

Patient Details

Sdec Mon 21 July 2025 16:00

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