Physician's Assistant

Refined clerking Sat 20 September 2025 22:17

Last Modified: 198 days ago

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Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Jaundice and feeling generally unwell

History of Presenting Complaint:
This 73-year-old lady presents with a 2-week history of feeling generally unwell. She reports pale coloured stools and generalised itching but denies dark urine or abdominal pain. She has been managing well at home in Darlington, walking up hills without breathlessness and remaining active with gardening. She lives independently and cares for her grandchildren. No associated nausea, vomiting, or significant weight loss noted. Recent blood tests revealed rising bilirubin levels (from 67 to 94 over 2 days) prompting urgent CT imaging.

Past Medical History:
• Left breast DCIS treated with wide local excision - mammogram surveillance with no evidence of recurrence, follow-up stopped January 2024
• Hypothyroidism - stable on thyroxine
• Hip arthritis

Drug History:
• Thyroxine (dose not specified)

Allergy History:
Not documented

Social History:
Lives independently in Darlington. Very active lifestyle including hill walking and gardening. Previous occupation as scientist at ICI Mortel. Cares for grandchildren. Mobility excellent - can walk briskly up hills without breathlessness. No formal care requirements.

On Examination:
General Appearance: Alert, well-appearing but jaundiced
Observations: Not fully documented
• Abdomen: Palpable solid mass felt in epigastric region described as 'pushing on something'
• Other systems: Not fully examined

Investigations:
• Bilirubin: 94 (increased from 67 two days prior)
• ALP: 606
• ALT: 509 (normal)
• CRP: 4
• Urea: 4.3
• FBC: Microcytosis and lymphocytosis without anaemia
• ECG: Sinus rhythm with first degree AV block, PR interval 214ms, no evidence of ischaemia
• CT Thorax/Abdomen/Pelvis: 24mm hypodense mass in head of pancreas with associated distal pancreatic duct dilatation and parenchymal atrophy. Marked CBD and intrahepatic duct dilatation. Mass does not involve adjacent organs or major vessels. No gallstones. Simple hepatic and renal cysts. No peritoneal deposits or ascites. Slightly prominent left para-aortic lymph nodes. No skeletal metastases. Staging T2N0Mx (indeterminate para-aortic lymph nodes)

Impression:
Pancreatic head mass with biliary obstruction - likely pancreatic adenocarcinoma
Differential Diagnoses: Rare pancreatic conditions that mimic malignancy
Obstructive jaundice secondary to pancreatic head mass

Management Plan:
1. Urgent ERCP for biliary decompression and tissue sampling
2. Blood tests: IgG4 levels and CA19-9 tumour markers
3. PET-CT to assess para-aortic lymph node involvement
4. Upper GI MDT referral for surgical evaluation
5. Upper GI CNS referral for patient support
6. Commence pancreatic enzyme replacement therapy for malabsorption
7. Nutritional supplements to prevent further weight loss
8. Gastroenterology ward admission for urgent workup
9. Full escalation plan to be discussed including fitness for major surgery (Whipple procedure)

Recheck bilirubin and inflammatory markers tomorrow morning. Consultant gastroenterologist review in morning to coordinate care plan.

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Refined clerking Sat 20 September 2025 22:17

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