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Patient Details

Refined clerking (27 weeks ago 04:50)

Refined clerking Mon 29 September 2025 04:50

Last Modified: 27 weeks ago

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Medical ST5 Miller Clerking

Presenting Complaint:
Melaena in stoma bag and shortness of breath

History of Presenting Complaint:
This 88-year-old gentleman presented with a 1-2 week history of increasing breathlessness and today noted melaena in his stoma bag. Feverish at home and had been coughing up clear phlegm

He was under Virtual Ward care receiving IV Tazocin for empyema diagnosed at Pleural Clinic on 19/09/2025. No NSAID or steroid use, nor haematemesis.

Background from Pleural Clinic: He had a 6-month history of 3 stone weight loss with loss of appetite. Progressive breathlessness over recent weeks with exercise tolerance reduced to 4 steps before becoming too breathless to continue. Long-standing non-productive cough. Mild ankle oedema since furosemide was reduced. Housebound for at least the last month, mobilising on wheeled zimmer frame.

Past Medical History:
• Empyema - diagnosed September 2025
• Atrial fibrillation
• Diverticular disease
• Chronic kidney disease stage 3
• Left cerebral infarction 2005
• Hypertension
• Gout
• Aortic stenosis

Drug History:
• Furosemide 20mg PO OD
• Bisoprolol 2.5mg PO OD
• Simvastatin 20mg PO ON
• Irbesartan 75mg PO OD
• Rivaroxaban 15mg PO OD
• Allopurinol 100mg PO OD

Allergy History:
NKDA

Social History:
Lives alone but supported by family including son. No formal package of care. Retired electrician, previously worked in military. Ex-smoker - stopped 1977. Drinks alcohol only occasionally. No known significant asbestos or occupational exposures. Previously independent but now housebound with zimmer frame mobility.

On Examination:
Observations: HR 130 (fast AF), BP 100/60, RR 22, O2 sats 89-90%
• Respiratory: Absent breath sounds right base with crepitations in right mid zone.
• Cardiovascular: Heart sounds normal, fast atrial fibrillation
• Abdomen: Stoma bag filled with melaena
• Other: Mild peripheral oedema to knees bilaterally. Slurred speech - long-standing from stroke but slightly worse. No new neurological deficits

Investigations:
• Hb 108 (19/09), 131 (26/09)
• Neutrophils 7 (raised from 4)
• Creatinine 107 (at baseline)
• Potassium and sodium normal
• Bilirubin 25 (chronically mildly elevated, improving from 24)
• CRP 151 (from 132)
• Urea 13.5 (from 5.9)
• VBG: pH 7.24 (from 7.38), lactate rising 5.6→11.9→13.1, glucose 3.6 (hypoglycaemic)
• ECG: Fast atrial fibrillation rate 130
• CXR: [/]
• CT Thorax/Abdomen/Pelvis (September 2025): Right pleural effusion with smooth pleural thickening and volume loss in right hemithorax. Plaques and emphysema. Partial collapse right middle and lower lobes with possible folded lung. Lung malignancy not entirely excluded. Indeterminate lymph nodes at right hilum and anterior tracheal region. L4 endplate fracture and generalised osteopenia
• Pleural fluid culture: Alpha haemolytic streptococcus (significance uncertain)

Impression:
Empyema with persistent infection despite antibiotic therapy
Atrial fibrillation with fast ventricular response
Upper gastrointestinal bleeding evidenced by melaena and raised urea
- Glasgow-Blatchford Score: 8

Management Plan:
1. IV antibiotics - changed from Tazocin to Meropenem and Teicoplanin as per microbiology advice [x]
2. Rate control - continue Digoxin loading - review rate after 6 hours and give further 500mcg if required. 
3. IV magnesium replacement [x]
4. Blood cultures and sputum MC&S [_]
5. Add Mg, Ca, Phos, TSH [/]
6. Inpatient OGD [_]
7. NBM pending OGD
9. Low threshold for cross-sectional imaging if develops abdominal pain given raised lactate
10. Catheterisation and strict IO monitoring
11. Cardiac monitor while in FAF
12. AMU
13. DNACPR in place from previous admission - for active ward-based care, not ICU

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Refined clerking Mon 29 September 2025 04:50

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