Physician's Assistant

Patient Details

Refined clerking (89 days ago 04:11)

Refined clerking Wed 07 January 2026 04:11

Last Modified: 89 days ago

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Medical ST5 Miller Clerking
07/01/2026 04:00

Presenting Complaint:
73-year-old gentleman presents with fever

History of Presenting Complaint:
Problems began several months ago when he started passing blood per rectum. Subsequently developed fevers and was admitted December 2025 with multidrug-resistant E. coli bacteraemia secondary to pelvic collection secondary to fistula, and COVID-19 (treated with remdesevir).

MRI pelvis demonstrated posterior transphincteric fistula communicating with abscess collection in left puborectalis muscle. Planned for surgical review following discharge but this has not yet happened.

Currently feverish, feeling unwell, and reporting change in urine colour (green/brown). No abdominal pain, cough, cold, SOB (more than usual fibrosis), sore throat or dysuria.

Patient stopped nintedanib during previous admission, currently on increased prednisolone 25mg daily (increased to 30mg from usual 15mg due to illness and part way through wean).

Past Medical History:
• Progressive interstitial lung disease (previously on nintedanib)
    - Pulmonary hypertension
    - Left-sided severe atrial dilatation with mitral valve stenosis and regurgitation as well as aortic valve disease
    - Most recent TTE - Preserved ejection fraction (60%)
    - Hypersensitivity pneumonitis
• Hypertension
• CKD 3a
• Ischaemic heart disease
• Steatotic liver disease
• Non-Hodgkin's lymphoma 2016
• Atrial fibrillation (on anticoagulation)
• Hypothyroidism
• Gout
• Diverticular disease
• Superficial low-grade bladder tumour 2025
    - TURBT March 2025 for bladder tumour
    - Ureteroscopic fragmentation of calculus and JJ stent insertion March 2025
    - Stent removal April 2025

Drug History:
• Atorvastatin 40mg PO ON
• Doxazosin 4mg PO OM, 6mg PO ON
• Nicorandil 10-20mg PO OM, 10mg PO ON
• Tilidiem LA 300mg PO OD
• Digoxin 125mcg PO OD
• Apixaban 5mg PO BD
• Omeprazole 40mg PO OD
• Prednisolone 25mg PO OD
• Mirtazapine 15mg PO ON
• Allopurinol 100-200mg PO OD
• Levothyroxine 50mcg PO OM

Allergy History:
NKDA

Social History:
Lives at home with wife in a house independently. Current smoker, drinks alcohol socially (approximately half bottle daily, stopped for 8 weeks recently then restarted).

On Examination:
Bilateral fine inspiratory crepitations to the mid-zones bilaterally
Pan-systolic murmur
Soft non tender abdomen
No oedema

Investigations:
• FBC: Hb 119, WCC 14.3, Neutrophils 12.27, MCV 76.1, Platelets 123, Lymphocytes 0.73
• U&Es: Albumin 34, Creatinine 100 (baseline), Sodium normal
• CRP: 198
• INR: 1.2
• Blood cultures (17/12/2025): E. coli - resistant to amoxicillin, co-amoxiclav, gentamicin, trimethoprim; sensitive to tazocin and ciprofloxacin
• MRI Pelvis (16/12/2025): Posterior transphincteric fistula with abscess in external sphincter and left puborectalis measuring 15mm transverse diameter containing locules of gas
• CXR: Bilateral hazy opacification R>L but stable in comparison to CXR from December.

Impression:
Recurrent infection and sepsis secondary to known pelvic collection secondary to transphincteric fistula
DDx: Chest sepsis but no respiratory symptoms
Offensive urine ?? developing colo-vesical fistula?
Anaemia - likely chronic disease

Management Plan:
1. IV Tazocin for multidrug-resistant E. coli
2. Double prednisolone to 30mg OD during acute illness
3. Surgical referral for management of pelvic collection +/- further imaging [/]
4. Haematinics
5. MSU
6. Admission destination to be decided between medical and surgical teams

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Refined clerking Wed 07 January 2026 04:11

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