Physician's Assistant

Patient Details

Rapidreview (89 days ago 00:05)

Rapidreview Wed 07 January 2026 00:05

Last Modified: 89 days ago

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Refined clerking (90 days ago 23:06)

Refined clerking Tue 06 January 2026 23:06

Last Modified: 90 days ago

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Medical ST5 Miller Clerking
06/01/2026 23:00

Presenting Complaint:
Epigastric pain and leg pain

History of Presenting Complaint:
Elective right total knee replacement on 26/11/2025. Post-operatively experienced nausea, dizziness, and acute tenderness in posterior knee and calf. USS leg veins on 24/12/2025 showed no evidence of DVT. On 24/12/2025 developed swollen hot right leg and was treated with antibiotics for presumed infection.

Attended ED on 04/01/2026 with one week history of palpitations, chest discomfort, and shortness of breath. Known atrial fibrillation. Diagnosed with DVT and commenced on Rivaroxaban for 28 days as per previous T&O recommendation.

Patient reports fever at home with severe epigastric pain described as sharp, not able to eat much. Not nauseated, vomiting. BO normally. Patient attributes this to known hiatus hernia.

Right calf pain as previously described as sharp, tight with significant pain associated with light touch

Past Medical History:
• Right total knee replacement (26/11/2025)
• Deep vein thrombosis (February 2025 and 2004)
• TIA (2024)
• Small vessel disease (August 2024)
• Grade 2 hypertensive retinopathy (2023)
• Ischaemic heart disease (2022)
• Hypertension
• Obesity
• Rheumatoid arthritis
• Diverticulitis
• Osteoarthritis
• Gastroenteric vascular ectasia
• Gastritis and oesophagitis (2014)
• Appendectomy (1975)
• Eczema
• Gallstones (2002) with cholecystectomy (2003)
• Total abdominal hysterectomy (2004)

Drug History:
• Lisinopril 10mg PO OD
• Aspirin 75mg PO OD
• Bisoprolol 2.5mg PO evening and 5mg PO morning
• Monomil XL 60mg PO morning
• GTN spray 1-2 doses SL PRN
• Atorvastatin 80mg PO nocte
• Lansoprazole 30mg PO morning (1-2 tablets)
• Lercanidipine 20mg PO OD
• Rivaroxaban (commenced post-DVT diagnosis)

Allergy History:
• Penicillin - anaphylaxis
• Stemetil - headache

Social History:
Lives in house with partner and daughter lives next-door
Non-smoker, non-drinker

On Examination:
• Cardiorespiratory: Soft pan-systolic non-radiating murmur, scattered bibasilal crepitations, 2L oxygen requirement
• Right leg: Very tender to touch throughout, feeling warm, no erythema. Wound on anterior aspect of right knee appears healthy with no dehiscence
• Left leg: Similarly warm but less swollen
• Abdomen: Profoundly tender in left iliac fossa and epigastrium with voluntary guarding

Investigations:
• CT Pulmonary Angiogram: Good opacification, no filling defect, negative for PE
• CXR (initial): Clear lungs, no pleural effusion
• CXR (05/01/2026): Peribronchial thickening, hazy increased opacification perihilar regions bilaterally, upper lobe diversion, subtle Kerley B lines left hemithorax suggesting heart failure
• Hb: 109 (previously 115 pre-op, 132 on 03/11, lowest 89 on 02/12)
• Platelets: 453
• RCC: 3.94 with microcytosis MCV 81.1, RDW 15.8
• Troponin: 7
• Creatinine: 93
• Sodium: 139, Potassium: 5.1
• ALP: 154, remainder of LFTs normal
• CRP: 31 (decreasing from peak of 247 on 28/11/2025)
• Urea: 8.5
• D-dimer: 1.5 (05/01/2026)

Impression:
Probable oesophagitis 
DDx Ischaemia related to hiatus hernia, alternative abdominal pathology
Right leg pain - unclear if expected post-operatively in context of fever and borderline inflammatory markers
Some investigations suggest possibility of CCF

Management Plan:
1. Analgesia for abdominal and leg pain
2. CT abdomen and pelvis [/] ± surgical discussion to exclude alternative abdominal pathology
3. Orthopaedic team review for leg pain [_]
4. Repeat Dopplers to exclude DVT given thrombosis history, immobility, recent operation, and high D-dimer [/]
5. If fever - blood cultures
6. Increase PPI
7. Continue Rivaroxaban but hold if surgical pathology on CT
8. AMU
9. TEP full escalation

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