Transcription - 20250921T 02-02.mp3

Roger harvey 758387 thanks very much for calling me about this gentleman presents with fresh red pr bleeding on a background of end stage renal disease for which he's receiving 3 times a week hemodialysis with through the team in exeter full stop he also has a background of coronary artery disease previous cabg in 1998 and multiple previous pci procedures for which he's at maximum revascularization full stop <\n\n> I know he was recently admitted in august and september with a vf cardiac arrest for which he required dc cardioversion and was placed on an amiodarone infusion following this following following return of spontaneous circulation following this full stop <\n\n> The surgical team have kindly been involved and have suggested a ct scan in order to gauge any bleeding in term in the way of ct pelvis with contrast full stop <\n\n> From my perspective I would think that ct angiography would be a better option to guide any potential in ir intervention and we're gonna discuss this with the radiologist on call to help guide which scan will be best full stop <\n\n> He's hypertensive with blood pressure 85 systolic on arrival heart rate 62 open brackets beta blocked so he's not beta blocked take you back heart rate 63 okay saturation is 98% on air and respiratory rate 17 full stop <\n\n> He following starting of blood he has his blood pressure has improved to 99 over 49 full stop pr bleeding is ongoing full stop <\n\n> Impression pr bleeding likely secondary to vasculopathy secondary to ckd plan discussed radiology regarding best scan in order to ascertain there is a target for in ir intervention full stop <\n\n> Or number 2 if hypertensive in the context of blood loss suggest activating the major hemorrhage protocol for urgent blood number 3 blood gases to monitor hemoglobin as well as potassium in the context of egfr of 8, 3 times a week hemodialysis and ongoing blood clot replacement which could increase the potassium full stop suggest stopping or holding clopidogrel and aspirin just suggest holding clopidogrel and continuing aspirin given cardiac stenting no could suspend isosorbide mononitrate if hypotension persists if indications for dialysis then discuss with team in exeter regarding urgent dialysis more than happy to advise regarding these but he has no current indications for urgent dialysis obviously we are concerned in the context of egfr of 8 in giving contrast however this is life threatening and he's on hemodialysis which will allow us to remove the contrast at his next dialysis session and any renal injury is unlikely to affect him in terms of contrast nephropathy to remain under the care of the surgical team given he presents with lower gi bleeding but more than happy to advise

PC:
Fresh red PR bleeding on background of end-stage renal disease.

HISTORY OF PRESENTING COMPLAINT:
This gentleman presents with fresh red PR bleeding. He has a background of end-stage renal disease for which he receives haemodialysis three times weekly through the team in Exeter. Recent admission in August-September 2025 complicated by VF cardiac arrest requiring DC cardioversion and amiodarone infusion following ROSC

PAST MEDICAL HISTORY:
1. Angina
2. Coronary heart disease
3. CABG 1998 [LA to LAD, vein graft circumflex, RCA diagonal (IMA non-functional)]
4. Multiple previous PCI procedures [most recently November 2024 RD&E]
5. CKD-5 [haemodialysis 3x per week RDE]
6. Preserved left ventricular function
7. Contrast allergy
8. Previous persistent atrial flutter
9. Bifascicular block
10. Anaemia

CURRENT MEDICATIONS:
Amiodarone 100mg BD, Clopidogrel 75mg OD, Aspirin 75mg OD, Isosorbide Mononitrate SR 60mg BD, Nicorandil 20mg BD, Atorvastatin 80mg nocte, Renovit, Renacet, Cholecalciferol, GTN spray

EXAMINATION:
Initial observations: BP 85mmHg systolic, HR 63, O2 sats 98% on air, RR 17
Following blood transfusion: BP improved to 99/49mmHg
PR bleeding ongoing

Suggest:
1. Discuss with radiology regarding best scan to ascertain target for IR intervention - ** note contrast allergy **
2. If hypotensive in context of blood loss, consider activating major haemorrhage protocol for urgent blood
3. Blood gases to monitor haemoglobin and potassium (given eGFR 8, 3x weekly haemodialysis, ongoing blood replacement could increase potassium)
4. Hold Clopidogrel and continue Aspirin given cardiac stenting history
5. Consider suspending Isosorbide Mononitrate if hypotension persists
6. If indications for dialysis arise, discuss with Exeter team regarding urgent dialysis, happy to advise
7. To remain under surgical team for lower GI bleeding management

Summary

Investigations

Plans

Medical ST5 Miller Clerking

Presenting Complaint:
Fresh red PR bleeding

History of Presenting Complaint:
Presents with ongoing fresh red PR bleeding. The bleeding is significant enough to cause hypotension with initial BP of 85 systolic on arrival. Blood pressure improved to 99/49 following blood transfusion, however PR bleeding remains ongoing. The bleeding is likely secondary to vasculopathy in the context of end stage renal disease.

Past Medical History:
• End stage renal disease - receiving haemodialysis 3x weekly through Exeter team, eGFR 8
• Coronary artery disease - CABG 1998, multiple previous PCI procedures, maximum revascularisation achieved
• VF cardiac arrest - August and September admissions, required DC cardioversion, placed on amiodarone infusion following ROSC
• Hypertension

Drug History:
• Atorvastatin 80mg PO OD
• Amlodipine 10mg PO OD
• Amiodarone 200mg PO OD
• Betahistine 16mg PO TDS
• Clopidogrel 75mg PO OD
• Colecalciferol 1000 units PO OD
• Alfacalcidol 500 nanograms PO OD
• Lansoprazole 30mg PO OD
• Nicorandil 20mg PO BD
• Sevelamer 800mg PO TDS
• Paracetamol 1g PO QDS
• Renavit 1 tablet PO OD
• Isosorbide mononitrate MR 120mg PO OD
• GTN spray 1 application sublingual PRN
• Lorazepam 0.5mg PO PRN max BD

Allergy History:
Unknown

Social History:
Unknown

On Examination:
General Appearance: Hypotensive on arrival
Observations: HR 63 (beta blocked), BP initially 85 systolic improving to 99/49 post-transfusion, O2 sats 98% on air, RR 17

Investigations:
Unknown

Impression:
Fresh red PR bleeding likely secondary to vasculopathy in context of chronic kidney disease
Secondary issues: End stage renal disease, coronary artery disease with maximum revascularisation, recent VF arrest

Management Plan:
1. Major haemorrhage protocol activated for urgent blood products
2. Discussion with radiology regarding optimal imaging - CT angiography vs CT pelvis with contrast to assess for IR intervention target
3. Serial blood gases to monitor haemoglobin and potassium levels given eGFR 8 and ongoing blood replacement
4. Hold clopidogrel, continue aspirin given cardiac stenting history
5. Consider suspending isosorbide mononitrate if hypotension persists
6. Contrast administration acceptable despite eGFR 8 as life-threatening condition and dialysis will remove contrast
7. Remain under surgical team care for lower GI bleeding
8. Discuss with Exeter dialysis team if urgent dialysis indicated

Summary

Investigations

Plans