Physician's Assistant

Refined clerking Wed 05 November 2025 19:45

Last Modified: 152 days ago

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Medical ST5 Miller Clerking

Presenting Complaint:
Recurrent biliary pain

History of Presenting Complaint:
Patient underwent gallbladder surgery in March 2025 performed by Mr Sinha. Since the operation, she has experienced increasingly frequent episodes of severe abdominal pain. Initially episodes occurred occasionally, but over the last couple of months they have become progressively more frequent, now occurring every other week. Most recent episode was Monday, with current presentation representing escalating pattern.

Pain episodes are severe enough to require hospital attendance and have significantly impacted quality of life.

Past Medical History:
• Laparoscopic cholecystectomy - March 2025 (Mr Sinner)
• Previous attendance August 2025 for same presenting complaint

Drug History:
• Codeine - PRN for biliary pain episodes
• Buscopan - tried previously, reported worsening of symptoms
• Paracetamol - rarely uses for routine pain relief

Allergy History:
• NKDA

Social History:
Lives with partner and children including 7-month-old baby
Partner works away some days (4-5 hours travel time), creating additional childcare concerns
Currently employed
Reduced alcohol intake - now mainly soy milk
Non-smoker
Functional Status: Significantly impacted by pain episodes, unable to function during attacks

On Examination:
General Appearance: Well, alert, not currently in distress
Observations: Not documented
• Abdomen: Not documented in detail
• Other systems: Not examined

Investigations:
• MRI scan (Recent): 8mm stone in bile duct system, one stone in cystic duct
• Blood tests (Recent): No evidence of infection or inflammation in bile ducts
• Previous CT scan: Unable to visualise stones

Impression:
Retained common bile duct stone post-cholecystectomy
Recurrent biliary colic secondary to ductal obstruction

Management Plan:
1. Urgent ERCP (Endoscopic Retrograde Cholangiopancreatography) for stone extraction
2. Coordinate care with surgical team - letter to Mr Sinha (original surgeon)
3. Multidisciplinary discussion with gastroenterology consultant regarding optimal approach
4. Letter to Mr Mansfield (Exeter) to avoid duplication of care
5. Patient education regarding ERCP procedure risks (3-4% complication rate, <0.5% mortality)
6. Plan for procedure within 1-2 weeks on twice-weekly ERCP list
7. Copy patient into correspondence for work purposes
8. Safety netting advice regarding signs of infection (jaundice, fever) requiring urgent medical attention

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Investigations:

Refined clerking Wed 05 November 2025 19:45

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