Physician's Assistant

Refined clerking Fri 09 January 2026 06:15

Last Modified: 87 days ago

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Medical ST5 Miller Clerking
09/01/2026 06:20

Presenting Complaint:
Diarrhoea and vomiting

History of Presenting Complaint:
81-year-old lady presented with one week history of diarrhoea and abdominal pain. Had received three courses of nitrofurantoin for presumed UTI, though patient states urine dips were negative.

On 3rd January, developed watery diarrhoea lasting 12 hours overnight with abdominal cramping. This continued for two nights with clear fluid passing progressing to blood-stained fluid.

Nausea associated with retching but without vomiting, particularly after eating or drinking.

Episodes of cramping and spasming pain occurred whenever attempting oral intake. No fever or rigors reported.

GP prescribed metronidazole for suspected antibiotic-associated diarrhoea, along with buscopan, loperamide (she is not taking this), dioralyte and antiemetics. Bowels not opened for 3 days prior to presentation. Significant weight loss from 9 stone 3 pounds to 8 stone 9 pounds over one week. Feeling dehydrated and weak.

Past Medical History:
• Psoriatic arthritis - on methotrexate 20mg weekly
• Acquired hypothyroidism
• Hiatus hernia
• Gastric dysmotility (July 2025)
• Asthma
• Chronic kidney disease stage 3
• Age-related macular degeneration
• Cataracts - both eyes
• Gilbert syndrome

Drug History:
• Levothyroxine 100mcg PO OD
• Methotrexate 20mg PO weekly (Sundays)
• Folic acid 5mg PO OD (except methotrexate day)
• Rosuvastatin 5mg PO OD
• Famotidine 20mg PO OD
• Gaviscon Advance 5-10ml QDS
• Fostair inhaler 100/6mcg 2 puffs BD via spacer
• Salbutamol inhaler 2 puffs PRN
• Oxybutynin 2.5mg PO BD
• Laxido sachets PRN
• Colpermin capsules TDS PRN

Allergy History:
NKDA

Social History:
Lives alone in bungalow. Daughter visits daily. Independent with activities of daily living normally. Ex-registered nurse, previously ran hotel and holiday flats. Non-smoker. Minimal alcohol.

On Examination:
• Abdomen: Soft, tender left iliac fossa, bowel sounds present
• Cardiovascular: Heart sounds normal, no murmurs
• Respiratory: Clear chest, no wheeze
• Other: Mild psoriatic arthritis changes in hands

Investigations:
• ALP 342 (previously normal)
• ALT 349 (previously normal)
• Creatinine 71 (baseline)
• Albumin 37, Total protein 55
• Bilirubin 21
• CRP 50 (previously <1 in October 2025)
• Urea 4.8
• FBC: Low red cell count, no anaemia, no neutrophilia
• VBG: pH 7.41, Na 131, K 3.2, lactate 0.6
• CT Thorax/Abdomen/Pelvis (12th December 2025): Stable lung nodules, small hepatic cyst, normal biliary tree, moderate faecal loading consistent with constipation/slow transit, no evidence of malignancy

Impression:
Timeline of diarrhoea with raised inflammatory markers makes antibiotic-associated diarrhoea or C. difficile a possibility
- Unless there is a significant complication I would not expect her not to open bowels for 3 days with this though
- Clinically I don't think a complication is very likely
Possibly overflow diarrhoea
- Unclear cause of raised inflammatory markers in that context

Management Plan:
1. IV fluids
2. Plain abdominal X-ray to assess for faecal loading and exclude complications
3. Stool culture and C. difficile toxin
4. Continue current antibiotics and symptomatic treatment
5. Bowel chart
6. Dietetic review for nutritional support given significant weight loss
7. AMU
8. TEP: Full escalation

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Summary:

Investigations:

Refined clerking Fri 09 January 2026 06:15

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