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Refined clerking (3 weeks ago 15:43)

Refined clerking Mon 16 March 2026 15:43

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Medical ST5 Miller Clerking
Date: 16/03/2026 15:43

Presenting Complaint:
Unilateral weakness

History of Presenting Complaint:
Peter Francis is a 76-year-old gentleman with known T4N2M1 metastatic low rectal adenocarcinoma who presented to Torbay Hospital A&E with a several-day history of progressive left-sided weakness affecting both his left hand and left leg.

The left hand weakness began mid-week when he dropped his dinner plate whilst transferring it from the hob. He describes an inability to hold objects level and has been unable to maintain grip. The left leg is similarly weak; the right leg is unaffected. He has been mobilising around the house using furniture for support. He has not been able to manage stairs safely and has not left the house. He lives alone, with his daughter providing support from nearby.

No clear saddle anaesthesia described and symptoms clearly unilateral

Regarding his stoma, output has been minimal since yesterday lunchtime when he changed his bag. Prior to this, output had been normal. He takes laxatives regularly. He uses Oramorph for analgesia.

He sustained a fall on 14-15/03/2026 and has had back pain since.

He completed a course of palliative radiotherapy under Dr Chambers on 27/02/2026 and has noticed urinary urgency since.

Past Medical History:
- T4N2M1 metastatic low rectal adenocarcinoma with lung metastases and suspicious liver lesion
- Sigmoidoscopy 17/12/2025: ulcerated rectal tumour 10cm to the dentate line; circumferential necrotic ulceration; previous PR scope not tolerated, gastroscope used to pass through narrowed anus
- Flexible sigmoidoscopy and rectal biopsy: moderately differentiated adenocarcinoma
- MDT discussion 02/01/2026
- Laparoscopic loop defunctioning colostomy 23/12/2025 for advanced rectal stricture with impending obstruction
- Palliative radiotherapy (5 fractions) completed 27/02/2026
- Presented 2 months prior with change in bowel habit (loose stools 2-4 times/day), 3 weeks of lethargy and shortness of breath, and symptomatic anaemia; CT at that time demonstrated low rectal tumour with involved margin, lymphadenopathy, bilateral lung metastases and suspicious liver lesion
- Glaucoma (January 2025)
- Cataract (January 2025)
- Hypercholesterolaemia (2011)
- Gout (1994)

Drug History:
- Pregabalin 75mg PO BD
- Morphine modified-release 15mg PO BD
- Oramorph PO PRN
- Brinzolamide eye drops 1 drop both eyes BD
- Latanoprost eye drops 1 drop both eyes ON
- Atorvastatin 10mg PO ON
- Beclometasone nasal spray 2 puffs each nostril BD
- Allopurinol 100mg PO OD

Allergy History:
NKDA

Social History:
Living situation: Lives alone in a house with stairs.
Mobility: Mobilising using furniture for support only. Unable to manage independently since fall on 14-15/03/2026. Uses stick
Carers: Daughter lives nearby; assists with shopping and daily tasks. In contact with Rowcroft Hospice nursing team.
Occupation: Retired bank manager

On Examination:
- Abdomen: Stoma appears healthy. Passing flatus, some liquid stool in bag.
- Cardiovascular: HS Normal
- Respiratory: Chest clear
- Neurological: Left-sided weakness affecting left upper and lower limb. Right sided power preserved.
Spinal tenderness on palpation of the spine, particularly in the thoracic region following fall.

Investigations:
- Bloods: Hb 84 (acute on chronic and currently asymptomatic)
- CT Head: 2 cm enhancing lesion in the superior right parietal lobe with extensive surrounding oedema. This is consistent with a metastatic deposit

Impression:
Intracranial metastatic disease with peritumoral oedema causing left-sided hemiparesis, in the context of known T4N2M1 metastatic rectal adenocarcinoma.
Acute-on-chronic back pain following mechanical fall with bony tenderness on spinal palpation; concern regarding spinal metastases and possible pathological fracture or traumatic fracture
Not managing at home independently due to weakness

Management Plan:
1. Dexamethasone 4mg IV/PO stat, followed by Dexamethasone 4mg PO BD (08:00 and 14:00)
2. PPI (while on steroids)
3. Calcium and vit D replacement (while on steroids)
4. CT whole spine [/]
5. Acute oncology referral - discussed with registrar on-call
6. Referral to neuro-oncology MDT
7. MRI Head with contrast
8. Increase laxatives given reduced stoma output with opiate use
9. Admission to Turner Ward +/- AMU

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Refined clerking Mon 16 March 2026 15:43

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