Physician's Assistant

Patient Details

Referral (312 days ago 10:07)

Referral Thu 29 May 2025 10:07

Last Modified: 312 days ago

MRN:

Content:

Investigations:
Flexible sigmoidoscopy December 2024: Radiation proctitis but no active bleeding seen at that time
Haemoglobin 85 on admission with CRP 94, creatinine 118, troponin 46 to 935
Subsequent haemoglobin 80. Bloods today awaited.
Flexible sigmoidoscopy May 2025: Moderate neovascularisation consistent with radiation proctitis, fresh blood ++, lifting solution injected followed by- adrenaline and APC

Thank you for asking me to review this 85-year-old gentleman with a background of type 2 diabetes, hypercholesterolaemia, STEMI with PCI in November 2024 (on dual antiplatelet therapy for one year), prostate cancer with bony metastases treated with radiotherapy leading to radiation proctopathy.

He presented with collapse at home yesterday morning and has been experiencing daily PR bleeding. He describes passing both fresh red blood with bowel motions and between bowel motions. He notes hard stools and has started laxido for this. He underwent flexible sigmoidoscopy with APC treatment one week ago which has not yet shown significant improvement in bleeding. Overnight he passed a 3-inch motion of congealed blood.

He also describes chronic chest discomfort for 2-3 years, worse on exertion and gradients, but stable. His troponin rise appears consistent with type 2 MI secondary to anaemia. He previously declined open heart surgery.

On examination, he appears better but still wobbly. His haemoglobin has dropped from 85 to 80 despite one unit of blood transfusion.

Impression:
Radiation proctopathy with ongoing significant PR bleeding causing anaemia 
Type 2 MI most likely
Challenging antiplatelet balance

Suggest:
1. Further blood tests today to check haemoglobin post-transfusion
2. Consider further blood transfusion if haemoglobin remains low
3. Commence sucralfate enemas up to four times daily (can use oral preparation drawn up in syringe if enemas unavailable)
4. Discuss with Dr Dunlop regarding timing of repeat flexible sigmoidoscopy and APC treatment
5. Continue laxido to keep stools soft
6. Monitor for further PR bleeding
7. Challenging antiplatelet balance

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Patient Details

Referral Thu 29 May 2025 10:07

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