Physician's Assistant

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Medical ST5 Miller Clerking
22/02/2026 20:02

Presenting Complaint:
Haematemesis

History of Presenting Complaint:
A 58-year-old lady presented following an episode of haematemesis in the early hours of this morning. She reported vomiting approximately four times in quick succession, with each episode producing a significant volume of bright red blood — estimated at approximately two litres in total. She did not seek medical attention overnight as she is the sole carer for her father and was reluctant to leave him; she also noted the bleeding had appeared to settle spontaneously.

No melaena. Bowels last opened yesterday - brown.

On direct questioning, she disclosed a longstanding history of significant alcohol use, drinking most evenings, with a previous history of drinking up to a bottle per day for several decades. She reported she had reduced her intake more recently. On examination, she appeared tremulous and diaphoretic, raising concern for early alcohol withdrawal in the context of being unable to drink following haematemesis.

She was noted to have a background of osteoarthritis of the hip awaiting replacement, which significantly limits her mobility and independence.

Past Medical History:
• Osteoarthritis of the hip — awaiting hip replacement (referred July 2025)
• Type 2 diabetes mellitus (diagnosed 2022)
• Asthma
• Migraine
• Hypertension
• Alcohol-related liver disease — first presentation (this admission)

Drug History:
• Bempedoic acid 180mg PO OD
• Metformin modified-release 500mg PO with breakfast and 500mg PO with evening meal
• Candesartan 16mg PO BD
• Sertraline 100mg PO OD
• Amlodipine 10mg PO OD

Allergy History: no
NKDA

Social History:
Lives in a house with her father, for whom she provides 24-hour care.
Mobilises with a wheeled walker indoors. Unable to manage stairs due to painful hip (AVN). Housebound
Longstanding history of alcohol use. Previously drinking up to a bottle of wine per day for several decades. More recently drinking most evenings, typically one to two glasses of wine. Not drinking in the mornings.

On Examination:
Unwell-appearing lady, tremulous and diaphoretic.
Observations: HR 109, BP 149/94, RR 18, SpO2 98%
• Abdomen: Bedside ultrasound performed — liver appears echogenic, consistent with hepatic steatosis. Gallbladder visualised with a small calculus, unlikely to be clinically significant. No ascites identified. Splenomegaly.
• Cardiovascular: Palmar erythema. Spider naevi visible on the chest, consistent with portal hypertension.
• Respiratory: Clear chest
• No peripheral oedema

Investigations:
• PT 51.1 seconds
• Prothrombin time 23 seconds
• INR 1.6
• Fibrinogen 1.7
• APTT ratio 1.29
• Venous blood gas lactate 4.8
• Hb 74 — previously 97 in December 2021

Impression:
First presentation of decompensated alcohol-related liver disease with GI bleeding
- Clinical evidence of portal hypertension (spider naevi, palmar erythema, splenomegaly) and upper GI bleeding, from varices or oesophagitis 
- Coagulopathy
Early alcohol withdrawal

Management Plan:
1. Repeat venous blood gas now, monitor haemoglobin x2 overnight - if dropping, consider further transfusion (one unit of packed red cells already transfused for Hb 74).
2. Formal liver ultrasound scan; ECG; blood cultures and MSU to complete septic screen; CXR
3. Medications:
   a. IV fluids for resuscitation and maintenance
   b. Pabrinex
   c. Chlordiazepoxide
   d. Vitamin K 10mg IV OD for 3 days
   e. IV Tazocin
   f. Proton pump inhibitor — to cover possible underlying oesophagitis
   g. If further haematemesis: Terlipressin 2mg IV and urgent discussion with on-call endoscopist
   h. Nutritional supplementation
4. OGD mane if stable - NBM
5. Detailed discussion held with patient regarding the likely diagnosis of alcohol-related liver cirrhosis, the significant mortality risk of continued alcohol use and the markedly improved prognosis with abstinence. Patient was counselled on the importance of complete alcohol abstinence.
6. ACT
7. Allerton Ward only (Via AMU if required)
8. Full escalation

Summary:

Investigations:

Refined clerking Sun 22 February 2026 20:02

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