Physician's Assistant

Patient Details

Refined clerking (66 days ago 20:44)

Refined clerking Fri 30 January 2026 20:44

Last Modified: 66 days ago

MRN:

Content:

Medical ST5 Miller Clerking
20:44 30/01/2026

Presenting Complaint:
Right leg cellulitis

History of Presenting Complaint:
Seen in the waiting room.
This 34-year-old gentleman presented with a 6-day history of diarrhoea and vomiting which has since resolved. Six days ago he woke with a swollen, red right leg consistent with cellulitis. The infection appears to be spreading from his chronic right fourth metatarsal head ulcer. He reports the cellulitis has been spreading upwards towards his groin over the past few nights. The right leg is the same limb that has been previously infected. He has been managing the ulcer with compression dressings applied by district nurses. His blood sugars became elevated during the acute illness but he has brought them back under control. He denies shortness of breath but reports feeling washed out and unwell. He experiences chronic back pain requiring him to sleep propped up on 4 pillows since having COVID.

Past Medical History:
• Type 1 diabetes mellitus with autonomic and sensory neuropathy
• Diabetic retinopathy (proliferative)
• Diabetic nephropathy
• Multiple DKA admissions (2004, 2010, 2011)
• Chronic kidney disease stage 2-3
• Recurrent cellulitis
• Bilateral Charcot arthropathy
• Chronic right fourth metatarsal head neuropathic ulcer
• Metabolic associated steatotic liver disease
• Hypertension
• Ocular hypertension/glaucoma
• Mild LVH on echo (August 2021) with EF 55%, trace mitral regurgitation
• BMI 54

Drug History:
• Aflibercept (eye drops)
• Atorvastatin 40mg PO OD
• Ezetimibe 10mg PO OD
• Levemir insulin 42 units BD (morning and evening)
• NovoRapid insulin on carb counting (5-10 units typically)
• Sertraline 100mg PO as directed
• Indapamide 2.5mg PO OM
• Brinzolamide 10mg/mL eye drops 1 drop BD both eyes
• Amlodipine 10mg PO OD
• Folic acid 5mg PO OD
• Stexerol D3 1000 unit tablets PO OD
• Ramipril 10mg PO OD
• Codeine 30mg PO 1-2 tablets QDS
• Versatis (Lidocaine) 700mg medicated plasters (apply 12 hours, remove 12 hours)

Allergy History:
• Amoxicillin
• Clarithromycin
• Clindamycin
• Co-trimoxazole
• Duloxetine
• Erythromycin
• Trimethoprim
• Venlafaxine

Social History:
Mobilises with crutches. Pain limits exertion. Able to dress, wash and do light housework including hoovering but cannot do anything heavier. Sleeps on 4 pillows due to back pain since having COVID. Lives independently but requires district nursing support for ulcer care.

On Examination:
General Appearance: Unwell, sweaty and clammy
• Cardiovascular: Heart sounds normal,
• Respiratory: Chest clear but poor breath sounds bilaterally
• Right leg: Very red cellulitis extending from foot ulcer up to groin area
• Tongue: Coated and dry

Investigations:
• Albumin: 34
• ALP: 197 (consistent with bone disease)
• Sodium: 131 (previously 138)
• Potassium: Normal
• Creatinine: 286 (from baseline 130)
• AKI stage 2
• eGFR: 24 (from 62)
• ALT: 64 (raised from previous 33)
• CRP: 343 (from previously 6)
• Urea: 23.6 (from 6.8)
• BSL: 85
• Phosphate: 1.12
• Magnesium: 1.07
• Hb: 113 (from 140)
• WCC: 19.5 (from 8.9)
• Platelets: Normal
• Neutrophils: 16.17
• VBG: pH 7.35, lactate 2.1
• Microbiology (12/24/2025): MSSA from right leg wound swab, susceptible to flucloxacillin, linezolid and trimethoprim, resistant to penicillin, doxycycline, clindamycin and clarithromycin
• Current blood cultures negative.

Impression:
Stage 2 AKI secondary to right leg cellulitis secondary to infected right fourth metatarsal head diabetic ulcer

Management Plan:
1. Move to bed as soon as possible
2. IV fluids for AKI
3. Antibiotics to be guided by microbiology (consider PO cephalexin based on sensitivities and allergies)
- Ceftriaxone 3g IV once daily
- Continue treatment over weekend
- Review if no improvement and contact microbiology for further discussion
- Current renal function acceptable for once daily dosing
4. Chest X-ray [/]
5. Urine MC&S [_]
6. Wound swab from leg for further sensitivities [_]
7. Blood cultures [/]
8. HbA1c  - addon [/]
9. Daily U&Es while AKI present
10. Input/output monitoring
11. Urine dip
12. Diabetic team review
13. Consider vascular surgery review given recurrent cellulitis and non-healing ulcer
14. TEP for full escalation planning
15. Pharmacological VTE prophylaxis
16. Diabetes ward if possible
17. Hold Indapamide and Ramipril in AKI

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Custom (66 days ago 20:50)

Custom Fri 30 January 2026 20:50

Last Modified: 66 days ago

MRN:

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TELEPHONE CONSULTATION WITH ON-CALL MICROBIOLOGIST

Date: 30/01/2026
Time: 20:50
Consultant: Dr Rob (Medical Registrar, Torbay Hospital)
Microbiologist: On-call microbiologist

PATIENT DETAILS:
Name: Joe Diamond
MRN: 557847
Age: 34 years
Weight: >150kg
BMI: 54

CLINICAL HISTORY:
Significant comorbidities related to poorly controlled Type 1 diabetes mellitus:
- Autonomic and sensory neuropathy
- Diabetic retinopathy
- Diabetic nephropathy with CKD Stage 3
- Bilateral Charcot foot
- Chronic right metatarsal head ulcer
- Multiple admissions in the past year for infections and cellulitis

CURRENT PRESENTATION:
Infected leg ulcer with severe cellulitis extending up to groin. Patient presents with:
- CRP: 343 (previously 6)
- Creatinine: 286 μmol/L
- eGFR: 24 mL/min/1.73m²
- AKI Stage 2
- Lactate: within normal limits
- Clinically: entire right leg cellulitic and swollen up to groin

MICROBIOLOGY:
Wound swab 24/12/2025:
- Light growth Staphylococcus aureus (methicillin sensitive)
- Resistant to: clarithromycin, clindamycin, doxycycline, penicillin
- Sensitive to: trimethoprim, linezolid, flucloxacillin

ALLERGIES:
- Clindamycin
- Trimethoprim
- Penicillins

PREVIOUS TREATMENT:
January 2026 admission:
- IV ceftriaxone challenge dose 2g, then 4g once daily for 5-7 days
- Well tolerated
- Switched to oral cephalexin with fusidic acid

MICROBIOLOGIST RECOMMENDATIONS:
- Ceftriaxone 3g IV once daily (higher dose due to patient weight >150kg)
- Continue treatment over weekend
- Review if no improvement and contact microbiology for further discussion
- Current renal function acceptable for once daily dosing

PLAN:
Commence ceftriaxone 3g IV once daily and monitor clinical response over weekend.

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