Physician's Assistant

Refined clerking Sat 04 April 2026 21:02

Last Modified: 2 days ago

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Medical ST5 Miller Clerking
04/04/26 21:02

Presenting Complaint:
Left lower abdominal pain

History of Presenting Complaint:
Presented with a recent viral illness, described as a sickness bug, associated with nausea and fever/temperatures around 2 weeks ago. She remained at home, rested in bed, and took paracetamol and fluids. Since then she has felt generally unwell, with reduced sleep and some shortness of breath. Over the last weekend she developed pain down the left side, mainly in the left lower abdomen. She initially wondered if this was related to the recent infection but sought medical review due to persistence.

She saw her GP on Monday, had a urine test and was asked to have blood tests. Results showed mildly abnormal liver function tests. She reports intermittent fever only during the recent viral illness, with no recent travel, tattoos, alcohol excess, or illicit drug use. No new prescribed medications; she has been taking Biocare Immune supplement. She also reports pins and needles in her fingers and toes and a brief episode of dizziness with difficulty walking in a straight line, which has since improved. No cough or coryzal symptoms. Bowels are normal, with a normal stool this morning. Urinary frequency is slightly increased but urine otherwise normal. No vaginal discharge.

Past Medical History:
• Hypothyroidism
• Turner syndrome
• Hysterectomy

Drug History:
• Levothyroxine
• Citalopram
• Biocare Immune supplement

Allergy History:
• No known drug allergies

Social History:
Lives with partner.  
Cares for her sister, who has Down syndrome.  
Smoking: non-smoker.  
Alcohol: denies recent alcohol use.  
Illicit drugs: denies.  
Functional status affected recently by feeling unwell and difficulty walking around.

On Examination:
General appearance: Alert and well enough for discharge.  
Abdomen: Soft, tender in the left lower abdomen. No guarding. No right upper quadrant tenderness. Murphy’s sign negative. No abdominal findings to suggest cholecystitis.  
Cardiovascular: Heart sounds heard, no abnormalities reported. Peripheral pulses present.  
Respiratory: Breathlessness reported, chest examination not reported as abnormal.  
Neurological: Brief dizziness and pins and needles reported, no persistent focal deficit described.

Investigations:
• Liver function tests: Mildly elevated, with raised ALP and other liver enzymes; pattern felt more consistent with hepatobiliary source than bone source
• Bone profile: ALP abnormal, calcium normal
• Urine test (GP): Done prior to referral, result not stated

Impression:
Mild transaminitis / cholestatic liver biochemistry following recent viral illness.  
Differential Diagnoses: Gallstones / choledocholithiasis, viral hepatitis, post-viral hepatitis.

Management Plan:
1. Discharge home as clinically well.
2. Arrange repeat liver function tests tomorrow.
3. Arrange viral hepatitis screen, including hepatitis B and EBV.
4. Arrange abdominal ultrasound scan tomorrow to assess gallbladder and bile ducts.
5. No antibiotics indicated; no evidence of bacterial cholangitis.
6. Consider chest X-ray if breathlessness persists or if clinically indicated.

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Investigations:

Refined clerking Sat 04 April 2026 21:02

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