Miss Chloe Avery, 26

Major medical diagnoses

• Polycystic ovary syndrome (bilateral, USS-confirmed; biochemical — low SHBG) — on metformin, ?endometriosis being investigated
• Emotionally unstable personality disorder with recurrent depression (~10 yrs) and history of self-harm/overdose — currently on vortioxetine
• Recurrent/chronic costochondritis — multiple flares with severe chest pain, several A&E/SDEC attendances to exclude cardiac cause (current presenting issue)
• Chronic rhinosinusitis / nasal congestion (ENT — ?nasal polyps, reported mould allergy) and migraine

Relevant recent context

• Recurrent costochondritis dominates recent contacts — repeated fit notes, GTN-style private employer letter (Dec 2025), and ongoing eConsults. Pain severe in flares (up to 10/10, occasional vomiting), exacerbated by return to work/exertion; managed with PRN naproxen + omeprazole.
• PCOS: seen KCH/PRUH endocrinology, started metformin Nov 2025 → periods more regular, dysmenorrhoea improved; discharged to patient-initiated follow-up (12/12). Endocrine queried endometriosis → gynaecology referral pending (appt ~April 2026).
• Mental health: long EUPD/depression history; lamotrigine was started by CMHT (Oct 2024) but never re-issued, so she remains on vortioxetine 20mg alone. Multiple ADAPT (Oxleas) psychology assessment appointments offered.
• Cardiology: rapid-access chest pain clinic declined (atypical, young); direct-access echocardiogram requested Aug 2025 — outcome not on file.
• ENT: discharged April 2025 for non-attendance at CT paranasal sinuses (could re-refer). NKDA.
• Outstanding: medication review due (flagged Feb 2026); confirm echo result; chase gynae appointment.

E-consult summary

• 11 May 2026 — OCR-garbled reason ("contonogitis"); ongoing problem, requests review/examination by Dr Amin. In context most likely a recurrent costochondritis flare.

Past medical history

• Polycystic ovary syndrome (bilateral)
• Emotionally unstable personality disorder
• Recurrent / severe depression (~10 yrs)
• Suicide & self-harm — overdose 2017, recurrent cutting
• Costochondritis (recurrent/chronic) — ?pericarditis considered, not confirmed
• Migraine
• Insomnia
• Chronic mechanical low back pain (MRI normal; ?spondyloarthropathy excluded)
• IBS-type symptoms
• Recurrent UTI — incl. ESBL E. coli (Feb 2024)
• Menorrhagia / irregular heavy periods
• Chronic rhinitis / sinusitis (?nasal polyps)
• Rosacea; seborrhoeic dermatitis of scalp; scalp hair loss (dermatology-investigated)
• Recurrent ingrowing toenails (bilateral great toes)

Past surgical history

• Bilateral great-toenail avulsion with chemical cautery (Oct 2012)
• Bilateral lateral wedge resection of great toenails (Mar 2012)
• Multiple minor-surgery excisions/cautery of seborrhoeic keratoses (2022–2023; chest, back, nasolabial fold, vulval region, cheek)
• (Closed fracture L thumb 2009 — conservative, thumb spica)

Medications

Current / active

• Vortioxetine 20mg — one daily (on repeat; last issued Feb 2026)
• Metformin 500mg — one twice daily (for PCOS; started Nov 2025 — KCH endocrine)
• Tirzepatide (Mounjaro) — private: 10mg weekly per endocrine Oct 2025; 2.5mg issued via Numan Mar 2026
• Naproxen 250mg — up to TDS, max 1g/day (costochondritis)
• Omeprazole 20mg — one daily (gastroprotection with NSAID)
• Mometasone 50microgram/dose nasal spray — on repeat (chronic rhinitis)
• Melatonin 2mg MR — at night (insomnia/migraine)

Stopped / changed

• Lamotrigine — started by CMHT Oct 2024 but never re-issued/established; remained on vortioxetine alone
• Citalopram 10mg — earlier antidepressant, switched to vortioxetine
• Amitriptyline 10mg — past (sleep/headache)
• Hydroxyzine 25mg — past (sleep)
• Ibuprofen 400mg — past (costochondritis, switched to naproxen)
• Naproxen 500mg BD — past (reduced/changed to 250mg)
• Rigevidon (COCP) — stopped (mood change, irregular bleeding)
• Ethinylestradiol 30microgram/drospirenone 3mg (COCP) — past
• Mefenamic acid 500mg — past (dysmenorrhoea)
• Sumatriptan 50mg — past PRN (migraine)
• Ferrous fumarate 210mg — past (low ferritin/hair loss)

New from letters/discharge (note source)

• Magnesium oxide — OTC, recommended for migraine (ENT, Jan 2025)
• Dymista nasal spray — recommended (ENT, Jan 2025)
• Oramorph 10mg — given for chest pain (KCH SDEC, Jul 2025)

Past acute courses — antibiotics (recurrent toenail infections / UTI / sinusitis)

• Flucloxacillin
• Co-amoxiclav
• Amoxicillin
• Erythromycin
• Doxycycline
• Trimethoprim (ESBL-resistant)
• Nitrofurantoin 100mg MR (ESBL UTI, Feb 2024)
• Metronidazole

Past topical / other

• Betamethasone valerate 0.1% scalp application
• Clobetasol 0.05% scalp application
• Ketoconazole 2% (Nizoral) shampoo
• Ivermectin 10mg/g cream (rosacea)
• Fusidic acid 2% cream
• Mupirocin 2% nasal ointment
• Naseptin nasal cream
• Beclometasone nasal spray
• Hydrocortisone 1% cream/ointment (± miconazole)
• Clotrimazole 1% cream
• Salicylic acid/lactic acid paint (verruca)
• Chlorhexidine 4% solution (toenail wash)
• Laxido / ispaghula husk / mebeverine 135mg / Dioralyte (IBS, constipation)
• Lidocaine injection (minor-surgery local anaesthetic)

Key markers

• BMI 33.8 kg/m² (Jul 2025); weight 95 kg (Feb 2024) → 84.8 kg (Oct 2025) on Mounjaro
• BP 126/73 mmHg, pulse 104 (Oct 2025) — normotensive but mild resting tachycardia
• HbA1c 38 mmol/mol (Jan 2025) — non-diabetic
• Testosterone 1.3 nmol/L (normal) with low SHBG 20.1 nmol/L → biochemical PCOS; FSH 5.8 / LH 2.1 IU/L, oestradiol 96 pmol/L
• TFT normal (TSH 2.37, fT4 11.8); prolactin 204 mIU/L, cortisol 256 nmol/L — normal
• FBC normal (Hb 124–128 g/L, MCV 95); ferritin 43 µg/L (low-normal — relevant to hair loss)
• U&E normal (creat 71, eGFR >90); LFTs normal
• Cardiac work-up (SDEC Jul 2025): troponin negative, CRP negative, ECG normal sinus rhythm, CXR clear, WCC 12
• Note: Hb 108 g/L at UCC Dec 2024 with heavy menstrual bleeding/clots

Last admission

• 25 Jul 2025 — King's College Hospital, PRUH SDEC / Medical Assessment Day Unit. Sudden central chest pain radiating to upper back, worse lying flat, eased leaning forward, with SOB. ECG normal (no pericarditis), CXR clear, troponin/CRP negative. Impression: musculoskeletal chest pain / costochondritis — discharged same day on NSAID + PPI with safety-netting. (Patient additionally reports a further A&E attendance late Aug 2025 for a similar "attack" — no discharge summary on file.)