Physician's Assistant

Refined clerking Sat 02 August 2025 02:45

Last Modified: 247 days ago

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Medical ST4 Miller Clerking

Presenting Complaint:
Alcohol misuse

History of Presenting Complaint:
67-year-old gentleman with longstanding alcohol misuse disorder presented following 9-day binge after prolonged period of sobriety ("100 days").

Has been consuming 750ml-1L spirits daily (gin), with poor oral intake and minimal water consumption.

Developed intermittent non-radiating epigastric pain earlier today, now resolved. Experienced nausea and vomiting with brown streaks but no fresh blood. No melaena.

Has not eaten during this period and reports last urination approximately 24 hours prior to admission. Bowels not opened for one week. Family became concerned when patient missed phone calls, found him in poor condition and advised hospital attendance. Currently feels significantly better than 12 hours ago with cessation of alcohol and commencement of IV fluids. Reports mild bladder discomfort similar to previous episodes. Attends Harbour Centre for alcohol support including group sessions and acupuncture. Good family support network who monitor his wellbeing.

Past Medical History:
• Previous alcohol excess on background of depression and anxiety
• USS liver (20/8/23): smooth liver contour, coarse echotexture, no evidence of portal hypertension
• FibroScan (2/1/24): LSM 6.1 kPa, CAP 178 dB/m
• OGD (19/12/23): minor oesophagitis, no evidence of varices
• Previous admission with alcohol withdrawal symptoms
• Previous anterior myocardial infarction with non-sustained VT (May 2020)
• Heart failure
• CKD
• Hypertension
• Tiny gallstones on recent MRCP

Drug History:
• Aspirin 75mg PO OD
• Atorvastatin 80mg PO OD
• Carvedilol 6.25mg PO BD
• Famotidine 20mg PO OD
• Mirtazapine 45mg PO OD
• Ramipril 1.25mg PO OD
• Thiamine 100mg PO TDS
• Lansoprazole 15mg PO OD

Allergy History:
NKDA

Social History:
Lives alone, generally active when not drinking
Retired - former RAF aircraft engineer for 25 years, then computer work for 10 years
Non-smoker, does not vape
Receives support from Harbour Centre for alcohol dependency
Supportive family including niece who monitors his welfare
Good engagement with alcohol services

On Examination:
General Appearance: Alert, clinically dehydrated
Observations: HR 80bpm, BP 109/83mmHg, Temp 37°C, RR 16, O2 sats 98% on air
• Abdomen: Soft, mildly tender epigastrically, no masses or organomegaly, bowel sounds present. No asterixis or jaundice.
• Cardiovascular: Regular rate and rhythm, cool peripherally, no lower limb oedema
• Respiratory: Bilateral air entry, normal work of breathing

Investigations:
• Blood gases: Lactate 5.9 and 5.7 respectively
• FBC: Hb 176, Platelets 129
• LFTs: Bilirubin 26, ALT 159, ALP normal, Albumin normal
• U&Es: Normal electrolytes
• CRP: 4
• FibroScan (March 2025): 5.3 kPa, IQR/Med 15%
• MRCP (March 2025): Tiny gallstones, no features of acute cholecystitis
• Urine MC&S: Pending
• Chest X-ray: Pending
• Glucose 3.4

Impression:
Alcohol-related gastritis secondary to alcohol misuse disorder
Lactic acidosis secondary to alcohol excess, dehydration and hypoglycaemia
Possible urinary tract infection - but unlikely

Management Plan:
1. CIWA protocol with diazepam as required for alcohol withdrawal
2. Pabrinex IV for 3 days followed by oral thiamine and vitamin B co-strong
3. IV fluids for rehydration plus glucose replacement to aid lactate clearance
4. Antiemetics and PPI therapy (switch to Omeprazole and give IV)
5. Encourage oral intake and monitor nutritional status
6. Monitor LFTs for development of alcohol-related hepatitis
7. Urine MC&S and treat UTI if confirmed
8. Plan for hepatology or short stay ward
9. Alcohol liaison nurse referral
10. Continue engagement with Harbour Centre support services
11. Repeat Refeeding bloods and VBG mane to ensure lactate resolving
12. TEP: Full escalation

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Investigations:

Refined clerking Sat 02 August 2025 02:45

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