Physician's Assistant

Refined clerking Sat 29 November 2025 20:59

Last Modified: 128 days ago

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Content:

Medical ST5 Miller Clerking 20:30 29/11/2025

Presenting Complaint:
Right upper quadrant pain

History of Presenting Complaint:
This 53-year-old lady presented with acute right upper quadrant pain which she describes as feeling very similar to her previous gallstone symptoms.

Has had some intermittent symptoms over past months but worst today

The pain is not related to eating. She denies associated vomiting, diarrhoea, dysuria, haematuria, fevers, chest pain or shortness of breath.

Past Medical History:
• Laparoscopic cholecystectomy with bile duct ultrasound (April 2022) - no operative complications
• Laparoscopic sigmoid colectomy (2014)
• Weber A fibular fracture (October 2024)
• Ehlers myotomy (age 12)
• "Very high cholesterol"
• Left bundle branch block

Drug History:
• Propranolol - for anxiety
• Citalopram - for anxiety

Allergy History:
NKDA

Social History:
Works as a nurse lecturer at Plymouth University and at the Royal Devon and Exeter Hospital
Independent
Non-smoker
Non-drinker

On Examination:
General Appearance: Not specifically documented
• Cardiovascular: Heart sounds normal
• Respiratory: Chest sounds normal
• Abdomen: Right upper quadrant tenderness on deep palpation
• Other: No peripheral oedema or rashes

Investigations:
• Urea and electrolytes: Normal
• ALP: 196
• ALT: 96
• AST: 69
• Amylase: Normal
• CRP: 36
• Bilirubin: 10
• MCV: 81.6
• Lymphocytes: 0.89
• Remainder of FBC: Normal
• CT coronary angiogram (May 2025): CAD-RAD 2, mild stenosis in proximal LAD and RCA

Impression:
Possible retained stone post-cholecystectomy
In pain and says not able to manage pain at home

Plan:
1. Analgesia
2. Ultrasound abdomen - more sensitive for intraductal stones but low threshold for cross-sectional imaging if severe pain
3. If choledocholithiasis proven, arrange ERCP - procedure discussed briefly including risks and benefits
4. VTE prophylaxis pharmacological
5. Monitor inflammatory markers - if increasing, consider treatment for biliary infection
6. If pain controlled could go home awaiting outpatient ERCP
7. Full escalation

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Summary:

Investigations:

Refined clerking Sat 29 November 2025 20:59

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