Physician's Assistant

Refined clerking Tue 06 January 2026 05:23

Last Modified: 90 days ago

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Medical ST5 Miller Clerking

Presenting Complaint:
Melaena and syncope

History of Presenting Complaint:
78-year-old gentleman presenting with melaena and syncope. Over recent days appeared unwell and lightheaded when standing. Yesterday passed an entirely large liquid dark red bowel motion whilst standing. He became pale, clammy and nearly fainted. Care home staff noticed loose stools tinged with red over the last 2 days which were black this morning. Recently been prescribed naproxen and codeine for back pain a couple of weeks ago.

Past Medical History:
• Alzheimer's disease - early onset with aggressive behaviour, housebound
• Orthostatic hypotension (2021)
• Abdominal aortic aneurysm - 5.9cm (ultrasound December 2025) - awaiting vascular input appt today
• Metabolic dysfunction associated steatotic liver disease on USS
• Umbilical hernia repair (2021)
• Tonsillectomy and adenoidectomy (2014)

Drug History:
• Epimax cream only
• Recently started naproxen for back pain
• Recently started codeine for back pain

Allergy History:
NKDA

Social History:
Lives in care home.
Patient seems to enjoy life despite cognitive impairment.
No alcohol or smoking

On Examination:
Pale
• Cardiovascular: Normal heart sounds, no murmurs
• Respiratory: Chest clear on auscultation, good air entry bilaterally
• Abdomen: No abdominal pain on examination
No oedema

Investigations:
• Hb: 79
• WCC: 16.5
• RBC: 2.34
• MCV: 104.9
• Neutrophils: 12.85
• Urea: 15 (previous baseline 3.8)
• Calcium: Normal
• Renal function: Normal
• Electrolytes: Normal
• LFTs: Normal
• Venous blood gas lactate: 1.4
• INR: 1.4
• CRP: 1
• Ultrasound abdomen (December 2025): AAA 5.9cm, metabolic dysfunction associated steatotic liver disease, bladder diverticulae

Impression:
Upper GI bleed secondary to peptic ulceration secondary to naproxen use for back pain - GBS 14

Management Plan:
1. Stop naproxen 
2. IV PPI
3. Large bore IV access
4. Inpatient upper GI endoscopy with consent form 4 completed
5. Alternative analgesia for back pain (avoid NSAIDs)
6. Admission to Allerton ward via acute medical unit
7. Vascular surgery review for AAA (may see patient on ward) as planned
8. Transfuse aiming 70
9. Bloods mane

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Summary:

Investigations:

Refined clerking Tue 06 January 2026 05:23

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