Physician's Assistant

Patient Details

Refined clerking (9 days ago 16:39)

Refined clerking Sat 28 March 2026 16:39

Last Modified: 9 days ago

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Content:

Presenting Complaint:
Left leg cellulitis

History of Presenting Complaint:
45-year-old man with advanced metastatic cancer and intestinal obstruction, on TPN via PICC line and venting Ryles tube, reviewed with concern for left leg cellulitis. Over the past 3 to 4 days he has developed pain around the left knee with a red, hot area on the inner aspect of the left lower leg, associated with worsening left leg swelling. He had a temperature of 37.7°C at home. He was prescribed oral flucloxacillin the previous day but was unable to tolerate it reliably due to his gastrointestinal issues and difficulty with administration via his Ryles tube. He feels the leg pain improved slightly after one dose. There is concern about possible deep vein thrombosis as well as cellulitis. The PICC line site does not appear infected on initial inspection.

Past Medical History:
• Temporal lobe epilepsy, 1991
• Depression
• Sigmoid polyp on colonoscopy, 2022
• Large sigmoid cancer, diagnosed 2022
• Laparoscopic-assisted left hemicolectomy, 2022
• Recurrent metastatic disease with peritoneal, abdominal wall, para-aortic and left humeral involvement
• Excision of abdominal wall mass, peritonectomy, omentectomy, left hemicolectomy, excision of para-aortic nodule and left nephrectomy, July 2024
• Progressive metastatic disease with bowel strictures and obstruction, January 2026

Drug History:
• Sublingual fentanyl 100 micrograms PRN
• Paracetamol PRN
• Docusate 100mg PO BD
• Fluoxetine 7.5mg PO nocte
• Atomoxetine 40mg PO OD
• Macrogol sachets PO OD
• Flucloxacillin PO QDS
• Furosemide 40mg PO BD
• Clonidine via syringe pump for analgesia
• Antiemetics and PRN medications via syringe pump

Allergy History:
• NKDA

Social History:
Managed at home with community palliative care support. Receives TPN at home via PICC line for 12 hours daily using custom-made bags. Venting Ryles tube in situ. Requires syringe pumps at home. Currently under palliative care with prognosis felt to be measured in weeks.

On Examination:
Alert and engaging. 
Observations:: Temp 37.7°C at home
• Cardiovascular: Left leg more swollen than the right. Area of erythema and warmth on the inner aspect of the left lower leg. Tender on palpation.
• Other: PICC line site appears clean and not obviously infected. Left lower leg cellulitic area was warm, tender and slightly bruised in appearance. No purulent discharge from the ulcerated area.

Investigations:
• CRP: 200
• Left leg assessment: Cellulitic area on the inner left lower leg with swelling; concern for DVT as a concomitant possibility

Impression:
Left lower limb cellulitis with concern for possible concurrent deep vein thrombosis.  
Advanced metastatic gastrointestinal malignancy with malignant bowel obstruction, on home TPN via PICC line.

Management Plan:
1. Admit under the appropriate medical team for inpatient treatment.
2. Start intravenous antibiotics for presumed cellulitis.
3. Withhold TPN overnight while the PICC line is assessed for possible line infection.
4. Take blood cultures and review results before using the PICC line for TPN again.
5. If cultures are negative and the line remains uninfected, restart TPN via the PICC line.
6. Arrange assessment for possible DVT, as this was discussed as a concurrent possibility.
7. Continue symptom control and liaise with palliative care.

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Refined clerking Sat 28 March 2026 16:39

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