Physician's Assistant

Patient Details

Sdec (256 days ago 12:29)

Sdec Thu 24 July 2025 12:29

Last Modified: 256 days ago

MRN:

Content:

Presenting Complaint:
Pulmonary embolism found on CT imaging

Past Medical History
• T3 prostate cancer - currently on finasteride therapy, smooth prostate on DRE, urology follow-up in 6 months
• Atrial fibrillation - on aspirin, GP planning to start apixaban
• Acute urinary retention 8 weeks ago - catheter in situ for 3 months minimum
• Recent severe diarrhoea during hospital admission
• Postural hypotension with syncopal episodes 4 weeks ago
• Eye condition requiring surgery (appointment cancelled)

Diagnosis:
1. Pulmonary embolism - small peripheral emboli
2. Iron deficiency anaemia - likely secondary to chronic blood loss
3. Challenging anticoagulation in context of anaemia

I had the pleasure of meeting Mr Steven Epworth, a 77-year-old gentleman, in Same Day Emergency Care today.

Mr Epworth was referred following CT thorax, abdomen and pelvis performed by urology which demonstrated low density filling defects in the left lower lobe and segmental arteries with further filling defects in segmental and subsegmental arteries in the right lung, appearances consistent with pulmonary embolism.

He presented 8 weeks ago with acute urinary retention, requiring catheterisation. Initial haematuria has now resolved and catheter drainage is satisfactory. He was recently reviewed in urology clinic where his prostate was noted to be smooth on digital rectal examination. The plan is to continue finasteride therapy with catheter removal after 3 months minimum and urology review in 6 months.

Mr Epworth has a background of atrial fibrillation, currently managed with aspirin. His GP was planning to commence apixaban but deferred this pending specialist input. He experienced syncopal episodes 4 weeks ago, attributed to postural hypotension following severe diarrhoea during his recent hospital admission.

On examination today, he appeared comfortable with no acute distress. His vital signs were stable and oxygen saturations normal on room air.

His recent blood tests demonstrate a concerning pattern of iron deficiency anaemia with haemoglobin dropping from normal levels in May to current low levels. Nuclear medicine bone scan showed no evidence of metastatic disease.

Investigations:
CT Thorax, Abdomen and Pelvis: Small peripheral pulmonary emboli bilaterally, no evidence of colonic malignancy
Nuclear medicine bone scan: No metastatic disease
Recent bloods (16th): Iron deficiency anaemia, declining haemoglobin since May
ECG: Satisfactory, no evidence of heart strain

Plan:
1. Blood tests today to recheck haemoglobin and haematinics
2. If haemoglobin stable, commence anticoagulation with early review for repeat haemoglobin next week
3. Iron replacement therapy - IV iron infusion today given presence here and to avoid gastric irritation
4. Discussion regarding upper GI endoscopy for anaemia investigation - patient wishes to consider this and discuss on Monday
5. Continue aspirin alongside anticoagulation (different mechanisms of action)
6. Blood test review Monday/Tuesday to monitor haemoglobin on anticoagulation
7. Outpatient OGD to be arranged if patient agrees following discussion

Field Clipboard (for EPR paste)

Builds copy buttons from the headings currently in the note, and also lets you copy the entire note.

Summary:

Investigations:

Patient Details

Sdec Thu 24 July 2025 12:29

Field Clipboard (for EPR paste)

Tasks

Feedback