Physician's Assistant

Refined clerking Fri 20 February 2026 15:06

Last Modified: 41 days ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Melaena and collapse

History of Presenting Complaint:
2-day history of melaena. Passing black tarry stools approximately every hour for past 48 hours. No passage of normal stool during this period. Associated with new dry cough but no haemoptysis. No haematemesis reported. Denies chest pain, shortness of breath, dysuria or rashes.

Neighbour found patient collapsed in kitchen this morning after hearing her fall. Felt weak in kitchen when preparing her drink. No reported head injury or loss of consciousness.

Patient has formal carers visiting 3 times weekly for shopping and housekeeping since September 2025. Known ongoing alcohol use.

Relevant recent presentations include July 2025 admission following fall with intoxication resulting in left mandibular haematoma on CT. June 2024 admission with fall following alcohol excess, self-neglect, anaemia and multiple electrolyte abnormalities with low-grade fever. OGD at that time demonstrated severe oesophagitis with nodularity but no varices or active bleeding. Biopsies from small bowel polyp and oesophagus showed no concerning features.

Did not attend scheduled follow-up with Dr Summers in July 2024.

Past Medical History:
• Reflux oesophagitis - severe with nodularity (OGD June 2024)
• Alcohol dependency
• Macrocytosis - longstanding
• Recurrent falls secondary to alcohol excess
• Self-neglect

Drug History:
• Thiamine (not taking)
• Folic Acid (not taking)

Allergy History:
• NKDA

Social History:
Lives alone in own house. Formal carers attend 3 times weekly for shopping and housekeeping since September 2025. Concerns raised about adequacy of care package and potential supply of alcohol by carers. Mobile independently but recurrent falls. Current smoker of 5 roll-ups per day since age 13. Heavy ongoing alcohol use - estimated 1 mug of spirits daily (approximately equivalent to milk volume). Significant self-neglect noted.

On Examination:
Alert but appears unwell. Evidence of chronic liver disease with palmar erythema and spider naevi noted on upper chest. Appears poorly kept.

Observations: BP 150/79, HR 123, temperature and oxygen saturations not documented

• Cardiovascular: Normal heart sounds, tachycardic at 123bpm
• Respiratory: Wet-sounding cough, right basal crepitations noted
• Abdomen: Not formally documented
• Other: Fungal nail infection noted on examination

Investigations:
• Hb 80 (07/07/26, previously 130 on 07/07/25)
• Platelets 302
• MCV 100.8 (previously macrocytic)
• White cells 11
• Creatinine 63
• Eosinophils normal
• LFTs normal with normal synthetic function
• Amylase 102
• CRP 14 (previously 1)
• Urea 14.1
• AST 23
• Alcohol level undetectably low
• Venous blood gas: pH 7.33, lactate 9.3, glucose 12.9
• CT head (July 2025): Haematoma of left aspect of mandible
• OGD (June 2024): Severe oesophagitis with nodularity, no varices, no active bleeding

Impression:
Upper GI bleed in context of ongoing alcohol use disorder

Differential Diagnoses: Variceal haemorrhage (though no varices seen on previous OGD), peptic ulcer disease, Mallory-Weiss tear, oesophagitis

Secondary issues: Likely chest infection with right basal crepitations and raised inflammatory markers. Tachycardia likely secondary to bleeding or sepsis. Chronic liver disease with stigmata. Self-neglect with inadequate social care package. Risk of alcohol withdrawal in hospital.

Management Plan:
1. Admission to Allerton Ward (liver ward)
2. Full escalation status currently - resuscitation discussion deferred pending clinical stabilisation
3. Add on INR and consider vitamin K if elevated
4. Ultrasound liver to assess for chronic liver disease and portal hypertension
5. IV PPI to cover for peptic ulceration
6. Septic screening: chest X-ray, MSU
7. IV Tazocin 4.5g TDS for suspected chest infection and to cover possibility of spontaneous bacterial peritonitis
8. Alcohol withdrawal protocol with appropriate benzodiazepine cover
9. Physical VTE prophylaxis with TEDS only (no pharmacological prophylaxis given active bleeding)
10. OGD tomorrow for therapeutic intervention if bleeding source identified
11. If haemodynamic compromise develops, arrange urgent endoscopy and discuss with on-call endoscopist
12. Consider treatment for fungal nail infection once patient improved
13. Thorough social work review regarding adequacy of care package and concerns about carer provision of alcohol
14. Resuscitation status discussion to be revisited once stabilised - note made that patients with decompensated liver disease secondary to ongoing alcohol use have poor outcomes with intensive care

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Summary:

Investigations:

Tasks

Feedback

• Consider more systematic abdominal examination - no documentation of hepatomegaly, splenomegaly, ascites or organomegaly which are crucial in suspected chronic liver disease
• Missed opportunity to quantify alcohol intake more precisely using standard units - "1 mug of spirits" is vague for clinical documentation and treatment planning
• Should have documented previous attempts at alcohol cessation, engagement with addiction services, and patient's insight into alcohol-related harm
• Incomplete vital signs documentation - temperature and oxygen saturations not recorded despite suspected infection
• Resuscitation discussion handled appropriately by deferring until patient stabilised, but ensure this is revisited within 24-48 hours
• Good holistic approach addressing social circumstances and safeguarding concerns
• Excellent recognition of need for septic screen in context of raised inflammatory markers
• Consider documenting nutritional status and malnutrition risk given self-neglect history