Next patient behcet mozaffer m u z a f f e r 348114 73 year old gentleman medications list atorvastatin 40 mg at night doxazosin 2 mg at night total dose 4 mg in the morning and 6 mg in the evening nicarandil 10 mg or 20 mg in the morning and 10 mg in the evening tilidium la 300 capsules once per day doxazosin we've already done that digoxin hundred and 25 micrograms once a day apixaban 5 mg twice a day omeprazole 40 mg once a day prednisolone 5 10 mg once a day mirtazapine 15 mg at night allopurinol 100 mg or 200 mg each day levothyroxine 50 microgram tablets in the morning past medical history esbl steatohtic liver disease pulmonary hypertension bronchiectasis ischemic heart disease heart failure with normal ejection fraction diastolic dysfunction preserved systolic ejection fraction at 60% left sided severe atrial dilatation with mitral valve stenosis and regurgitation and aortic valve calcification hypertension superficial low grade bladder tumor neotic valve stenosis ckd 3 a interstitial fibrotic progressive interstitial lung disease on previously on nintanib allergic extrinsic allergic alveolitis 20 21 non hodgkin's lymphoma 2016 atrial fibrillation 2009 on anticoagulation hypothyroidism gout turbt march 2025 for his bladder tumor and ureteroscopic fragmentation of calculus and insertion of jj stent march 2025 subsequent stent removal april 2025 so discharge 12/18/2025 following an admission with a transphincteric with multiresistant e coli bacteremia and covid-nineteen managed on midgley ward admitted with fevers and breathlessness and underwent several investigations which demonstrated multidrug resistant e coli in his blood and had an mri of his pelvis showing a posterior transsphenteric fistula communicating with an abscess collection in the left puborectalis they've added diverticular disease to the past medical history he's also been remitted under the surgeons back in november where he was treated for pneumonia and pr bleeding to his nintendanib blood cultures negative so far inr 1.2 full blood count hemoglobin a 119 with with white white cells 14.3 neutrophils 12.27 mcv 76.1 platelets a 123 lymphopenia 0.73 nfts albumin 34 but remainder of lats 2 hemolyzed potassium hemolyzed with sodium normal and creatinine 100 which is at baseline for patient crp 198 plan so impression is a recurrent infection and sepsis secondary to known pelvic collection secondary to transphincteric fistula 4 plan is surgical referral for takeover of care given pelvic collection is leading to symptoms and we we'd be happy to advise regarding his interstitial lung disease number next consider cross sectional imaging depending on surgical opinion number next hematinics given anemia most likely to be anemia of chronic disease in this context number next antibiotics covering for previously cultured bug so a on the seventeenth december 20 25 from the blood cultures and escherichia coli was isolated which is resistant to amoxicillin co amoxiclav gentamicin and trimethoprim but sensitive to tazosin and ciprofloxacin so therefore suggests treating with tazosin and his mri of pelvis which is on the 12/16/2025 demonstrated posterior transphincteric fistula and an abscess which was in the external sphincter and left peep erectileus measuring up to 15 millimeters in transverse diameter and containing several locules of gas hi mister is in casa cool is it mister beshay yeah hi I'm rob I'm 1 of the doctors nice to meet you are you I'm 1 of the medical registrars you've been referred to us in medicine to come into hospital I don't know if you can hear me very well shall I take this out you might be able to hear me better yeah sorry okay and I'm 1 of the medical registrars I'm wrong alright you've been referred to us by the emergency department team because of the nasty infection you've got to come into hospital there's a concern about where the infection might be I see you're in hospital in december with that abscess in your pelvis has anything been done by about that since no and sorry the other review I don't wanna have to keep coming back all the time of course I always like that problem sort of no yes certainly that is do you have any pain in the tummy a fistula but do you have any pain in the tummy not on the bottom k on the back and how's and how's it going for a poo you pass are you opening your bowels okay a poo yes well I mean basically the the the story began a couple of months ago I was passing quite a bit of blood mhmm to my from the back and so my back to the hospital I went and I had a seboscopy mhmm and then he did and then he did a ct scan yes I never really got to know what what happened there but I never heard of him anymore so that was taken and then I started getting sometime I started getting fevers yes and then you had fevers this time yeah that's why you're really shaking not cold that's why I think any cough or cold or anything like that well cold no good and pain I've got I've got fibrosis oh yes I know about that and you were previously on an intendanib yeah you're taking the intendanib now an intendanib where you prescribed you stop I stopped them the last time I was here they said I shouldn't take I shouldn't take it I see and so double your steroids didn't you double your prednisolone how many steroids are you on at the moment I'm I'm currently on 25 mg a week a day and what dose are you on normally I was on 15 you're on 15 they doubled it at the 18 I've been trying to cut back yeah but because I've been feeling so rough I decided to stay on it for a while and what do you take the steroids for again is it for your lungs yeah for the iodine and in blue with having any mycophenolate on any tendon if you've got that instead because of extrinsic allergic alveolitis is that why which 1 because of extrinsic allergic alveolitis is that why you're on the steroids probably alveolitis yeah it's a it's a subtype of of fibrotic lungs and it responds well to steroids I don't know I don't I'm I'm sensitive pneumonitis hypersensitive pneumonitis fine okay that's good to know it's bit earlier right sometimes the management is done in exeter with these things is that what yours is or do you see someone here do you see someone here or someone in exeter I see somebody here now oh lovely is he doctor whitehead no doctor miller yeah that's lovely lovely so yeah so sorry I'm don't worry I'm asking you some questions can I have a quick listen to your chest is that alright yeah you'll just do some big breaths for me okay yeah does your breathing feel any more difficult than normal it does feel good I had a covid leftover mhmm well it's not coming up it's going to be direction between apparently I had the alveoli mhmm in my bladder in my urine yes and it's got a certain it it was was in your blood I do believe right probably over the not the last time leaving notes and it hasn't sealed the next year it's just pouring a breath 2 is not on the I've got 3 in on the discharge form already I'm just having a read he's gonna lie shortly you may have you may have both you may have had both yeah so e coli normally starts where in a we have a natural reservoir of e coli in our body yes in our: in the: mhmm and that can isn't it really spread to the bladder certainly it's all in the same place all in the pelvis it's all very close together your bladder's there your colon's there your prostate's there yeah and your collection your abscess is in that area right next to your bladder in colour so it's certainly the potential for the bacteria to move both into your blood and spread throughout your body and make you poorly and also into your bladder that can give you a colonisation of the bladder so what's causing all this do we know for sure that it's the fish sugar I suspect that's what's going on the abnormal connection between your: and the muscles in your pelvis has led to small bits of poo travelling down that track and into your pelvis that means that you just constantly have a stream of bacteria and things that bacteria like to grow on like your poo going into the wrong place then it lives there in this lovely warm environment and develops an abscess it's a weird color what color is it I don't know it's like green green and brown when I was very dark you might be very dehydrated certainly in the context of infection that's very common but there's also the potential for is there any are there any bubbles in your wink I'm just dehydrated no that's good that's fine that's good but it's it's not very nice hello it's swelling it's what is it funny color it pops in a very frequent and small amount what does it smell like well I reckon it was like rotten fish but I may even a little of fair enough certainly bacteria in there can give it that kind of smell we didn't see any abnormal connection between your bladder and your bowel during the mri scan which is just a bit so I doubt very much is food coming out alright so I'll just leave it well I'm say I because I've I've got this strain of e coli up yes the bowel can be quite difficult it's quite difficult to treat it's pretty it is I did read online that there are 2 2 medications out there that I quite live without mhmm yes I do have a question and your specific bug has been cultured in the laboratory and we know which medicines it's sensitive to so I'll put you on 1 of those medicines if that's okay yeah called tazosin alright well I would suggest what we do is give you on that medicine which works well for you the tazosin and speak to my surgical colleagues I think they're the people that really need to take this forward I think if you were admitted to hospital under them then that would be a good impetus for them to fix this pelvic collection for you which is the cause of your recurrent infection I agree with you 110 good I mean sounds like a plan yeah because it's it's gonna be like a pretty overwhelming zol really until you get that I'm going to do you seek an infection treatment I'm going go home and then the week 10 days later I'll be back it's going to happen that'd be good to get it sorted we do need to get it sorted I mean I would pay but according to my gp if it it's not possible yeah you can't go with it you can't do it privately yeah it's 1 thing having a knee replacement electively but it's another when you're quite poor and you need invasive hospital treatment yeah you don't really do the flush that privately so you're in the best place here okay alright so have you seen any results from me I've seen that your blood test showed that you've got raised inflammatory markers markers of infection and inflammation as we expected they're slightly anemic so I'll investigate why you're anaemic but probably the cause of that is a long standing infection because that can make your bone marrow start producing many red cells your kidneys are doing fine your liver's doing fine so that's good but yeah I haven't seen anything else we probably need to get some imaging in your tummy probably when I speak to my surgical colleague they'll suggest doing another ct scan yeah I mean that's a good idea I mean I do normally wake up with a with a back stomach mhmm but 1 last thing when I came in yesterday I what what I do I take tablets in some tablets in the morning and some in the evening mhmm I came in yesterday I brought my own morning ones in but I didn't use evening ones mhmm I wasn't asked about tablets but yesterday mhmm and I didn't take my evening ones so I'm a little bit concerned of course that I didn't take my evening 1 mhmm I've had a look at all of your medicines and I'll prescribe them I've had a look at all your medicines and I'll prescribe them for you so you can have them in a few hours' time in the morning does sound that alright when the nurse is coming around to do the drug yeah but I've missed the evening ones mhmm which ones have you missed that you take in the evening not a lot mhmm and the the thing is I've missed the prednisone especially the prednisone mhmm I was gonna get so it'll be 5 tablets 25 mg of prednisolone I was must admit I would suggest putting you back up to 30 when you're acutely ill like this yeah so I'll get you 30 mg of prednisolone now what about the rest of this couple more well I've had a look at your list I've got it on the computer in the other room but I must admit I can't remember them all but yeah I can like I say I will prescribe them all all the ones that you should continue for you if I if there are any that you take in the evening I can try and get them for you but realistically it's 04:00 in the morning now so you you may be better off cutting your losses and just having your rest of your medicine what's what's seats got 1 I take last evening as well as now well no well it's 04:00 in the morning now so it's only a couple of hours until you have your morning medicine and if you have all of your evening medicine now that might upset your ability to have your morning medicine it may be better to cut our losses and just have your morning medicine just cut your ones out but the prednisolone oh you definitely need I don't recall there were many other incredibly important medicines and thyroid yeah your thyroid you don't take in the morning no the thyroid I take it that's interesting yeah in the morning in the morning good so you would have taken it yesterday morning I would have taken it and you will have it again this morning there are very few medicines that you can't dismiss for a day don't worry it's probably good you didn't take your losartan anyway because your blood pressure has not been the most fantastic since you've been here anyway was it low yeah little bit not mega low but in the context of taking an antihypertensive it could be a lot last time I just got my liquor liquor advil something along with the along with the other ones I mentioned mhmm it's no it wasn't the they stopped the other 1 right alright I'll have a look at them I'll make sure we've right so what you're saying I'm gonna get this morning's tablets yes we're gonna be getting past 1 and stuff mate I think that's the best thing to do do you want me give you the prednisolone which I'll get for you now after the prednisolone no you want me to give you the list on my bag or not I've got them on the computer yeah but I don't wanna say of course you have it on your gp right we're talking about this morning aren't we yes so I only want the ones that I take in the morning mhmm the ones I normally take in the morning include as I said I prednisolone yes so I'll give you your prednisolone yeah but not double up obviously oh I would suggest having 30 mg of prednisolone this morning yeah just the 1 dose to for today the january 7 you'll have 30 mg of prednisolone I won't give you 30 mg now 30 mg in 4 hours time don't worry yeah sorry no no don't worry it's fine yeah no problem yeah it does here of course it's 04:00 in the morning I completely understand but don't worry that's my job alright well I'll make sure everything's good don't worry that's that's my why I work all night to make sure everything's good yeah you're you're up at 04:00 in the morning because you were away pool yesterday so you must be drinking all day yesterday so don't worry I'll sort everything out that's what I want about it okay who live with at home yeah my wife your wife do you live in a house or a flat a house not do you drink and smoke I I smoke I drink you drink a bit of alcohol socially yeah a little bit more than that I stopped for 8 weeks and I recently started it mhmm how much do you drink in the morning depends really on drinking I just I don't know maybe sometimes half a bottle a day at home fine why not not that sounds fine you drink every day not so it's not ideal but it's fine gotta have something to get through the winter and with the with the lung pain it seems to have got worse since the last time mhmm when I had the covid I thought there were many that's caused it having all this inflammation with this pelvic collection and all this stuff doesn't help your lungs does it mhmm it needs you to be in a non inflamed state I was supposed to have an appointment today here at the respiratory for a barium swallow test or not oh lovely and I reckon I might have some food when I'm oh to see whether it's going on the wrong way we could do that while you're in if you like what is that 10:30 in the morning I don't know yeah that's good down for it or mhmm can do it while you're in it another time we're in trouble yeah yeah I'll put it in a request for orientation once we alright well I'll take it off and offer you time no no you no thanks so much don't worry we'll we'll get it all sorted don't worry sorted as well nice to see you are you allergic no have a good day allergic no good mate you do a bowel upper 1 of the surgeons yeah yes thank you impression recurrent sepsis secondary to known pelvic collection plan tazosin bearing swallow is inpatient as previously planned by the respiratory team to exclude aspiration as a cause of respiratory deterioration surgical review + or - further imaging