Physician's Assistant

Refined clerking Fri 09 January 2026 04:29

Last Modified: 87 days ago

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Medical ST5 Miller Clerking
09/01/2026 04:30

Presenting Complaint:
Abdominal pain

History of Presenting Complaint:
This 59-year-old lady with locally advanced pancreatic cancer presents with worsening upper abdominal pain following recent ERCP and biliary stent insertion.

She underwent ERCP on 29th December 2025 for biliary obstruction secondary to locally advanced T4 N1 pancreatic malignancy, with successful placement of 6cm metal stent.

Patient had been managing well initially on oral morphine, escalated from 5mg BD to 20mg BD. Yesterday she felt well and slept soundly, however developed escalating abdominal pain through the day requiring PCA.

Pain is located in upper abdomen, described as worse than childbirth, associated with some pleuritic component. Patient reports feeling warm with documented low-grade pyrexia (37.1°C). Appetite has been poor with minimal oral intake - small breakfast and soup at lunch only. No vomiting but some nausea and reflux symptoms.

BNO today, no nausea or vomiting

Past Medical History:
• Locally advanced pancreatic cancer T4N1 with biliary obstruction (2025)
• Asthma
• Coeliac disease (2012)
• Osteopenia (2017)

Drug History:
• Laxido 1-2 sachets PRN
• Morphine sulfate 10mg/5ml oral solution 5-10ml QDS PRN (10-20mg QDS PRN)
• Creon 25000 capsules TDS PRN
• Esomeprazole 20mg PO OD
• Ibuprofen 400mg PO TDS
• Metoclopramide 10mg PO TDS
• Paracetamol 500mg-1g PO QDS PRN
• Symbicort 200/6 Turbuhaler 1 dose BD
• Evorel 50 patches every 3-4 days
• Vagirox vaginal tablets 1 twice weekly
• Testosterone transdermal gel 1/8 sachet daily
• Progesterone micronised 100mg 2 daily

Allergy History:
Penicillin - Rash

Social History:
With husband
Local GP
Son is anaesthetist in RDE

On Examination:
In pain, unable to move around the bed.
• Abdomen: Significant tenderness throughout abdomen, firm to touch with percussion tenderness
• Cardiovascular: Heart sounds normal, pulses regular
• Respiratory: Right lower zone crepitations
• Other: Euvolaemic, moist mucous membranes

Investigations:
• CT Pancreas (12/21/2025): Rapidly progressing pancreatic malignancy with poorly enhancing mass in uncinate process measuring 23mm diameter, soft tissue abutting SMA, SMV narrowed superiorly
• ERCP (29/12/2025): 6cm metal stent placed with good bile drainage
• Creatinine: 35
• Bilirubin: 42 (previous peak 81)
• ALT: 61 (improving)
• ALP: 187 (improving)
• Amylase: 39
• CRP: 73 (was 4 on 17/12)
• Urea: 3.6
• WCC: 13
• Neutrophils: 11.17
• Hb: 124
• Sodium: 128
• VBG pH: 7.39

Impression:
Increasing abdominal pain post-ERCP with raised inflammatory markers
Possible cholangitis secondary to biliary instrumentation
Differential Diagnoses: Perforation

Management Plan:
1. PCA for analgesia (already commenced)
2. CT abdomen and pelvis with contrast (vetted with radiologist)
3. IV antibiotics for suspected cholangitis
4. IV fluids
5. TEDs for now, consider LMWH if CT ok
6. ECG
7. Allerton ward - clarify with AMU whether can come there on PCA
8. If surgical pathology identified on CT, refer to surgical team

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Summary:

Investigations:

Refined clerking Fri 09 January 2026 04:29

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