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Issues review (104 days ago 11:37)

Issues review Tue 23 December 2025 11:37

Last Modified: 104 days ago

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Content:

Issues:
1. CT evidence of at least partial small bowel obstruction, potentially closed loop suspicious for internal hernia
- CT abdomen and pelvis 22/12/2025 showing appearance concerning for at least partial small bowel obstruction
- Potentially closed loop suspicious for internal hernia
- No CT evidence of bowel perforation or ischaemia
- Stable appearance of large anterior abdominal wall hernia containing loop of uncompromised transverse colon

2. Decompensated alcohol-related liver disease
- Jaundice with bilirubin 26
- Increased volume of ascites compared to previous CT from August 2025 despite diuresis
- Unclear compliance with medications
- No evidence of AKI
- No evidence of hepatic encephalopathy
- SBP yet to be excluded
- Coagulopathy yet to be investigated

3. Stable long-standing anaemia with normocytosis
- Hb 105 with normocytosis
- Might benefit from haematinics
- Last ferritin 22 in September 2025

4. Potential hepatic vein thrombus requiring further investigation of potential Budd-Chiari syndrome
- Filling defect within left hepatic vein in keeping with thrombus
- Main portal vein appears patent

59-year-old man with past medical history of 
decompensated alcohol-related liver disease with ascites managed with furosemide 40mg BD and spironolactone 100mg BD. 
Previous encephalopathy managed with rifaximin 550mg BD and lactulose 30ml BD. 
Previous upper GI bleeding - haematemesis in March 2025 with OGD demonstrating grade 1 varices without bleeding stigmata and portal hypertensive gastropathy. 
Previously on carvedilol for varices but held due to symptomatic hypotension and not restarted. 
Co-trimoxazole previously prescribed for SBP prophylaxis.

Other PMHx includes COPD, osteoporosis, vitamin D deficiency, hepatitis C carrier, IBS, anaemia.

Discharged 5 days prior to readmission from Haytor (psych unit) - unclear why admitted. Some mention of paranoia. 
Readmitted with lower abdominal pain radiating to back. 
Still drinking alcohol - 4 bottles of wine in last 4 days. 
Passing hard stools. Functionally unable to manage flight of stairs.

Most recent investigations:
- Bilirubin 26, ALP 143, CRP 7
- Hb 105 with normocytosis
- INR was 1.4 previously, now 1.1 in October (not rechecked since admission)
- CT findings as above showing portal hypertension features, perioesophageal and upper abdominal varices, mildly enlarged spleen at 13.1cm

Current medications: Spironolactone restarted, furosemide restarted, omeprazole, cefuroxime and metronidazole started 22/12/2025. Few doses of IV morphine recently prescribed.

Observations: NEWS 3, pulse 113, temperature 36.7°C, BP 109/77, RR 16, sats 90% on air

Examination:
Abdomen distended with tense grade 3 ascites. 
Large ventral abdominal wall hernia which is tense, fluctuant with ascites
No asterixis but Tremulous in-keeping with withdrawal
Very mild pedal oedema bilaterally. 
Dry tongue. 
Chest clear, heart sounds normal.
ECG: sinus tachy

Impression:
Partial small bowel obstruction on CT ?secondary to internal hernia - no plans for surgical intervention - felt to be anaesthetically and surgically high risk which I agree with
Decompensated alcohol-related liver disease with ascites and jaundice secondary to possible Budd-Chiari syndrome plus ongoing alcohol misuse

Suggest:
1. Bedside INR - INR 1.3
2. Stop oramorph and morphine sulphate
3. CT liver triple phase [_]
4. USS-Guided drain today - I will undertake
- Drain for 6 hours maximum then remove drain
- 100ml of 20% HAS for each 2.5L drained - see proforma
5. 2 days following drain, if renal function stable, increase spironolactone to 150mg BD
6. Start lactulose and rifaximin
7. CIWA & Pabrinex to continue
8. Nicotine replacement - patch and inhalator
9. Stop senna
10. Transfer to Allerton for joint care with surgeons and gastro

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Refined clerking (25 days ago 20:55)

Refined clerking Thu 12 March 2026 20:55

Last Modified: 25 days ago

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Medical ST5 Miller Clerking

Presenting Complaint:
Haematemesis

History of Presenting Complaint:
The patient presented after an episode of vomiting blood in the early hours of the morning, with fresh red blood noted in vomitus. He reported dizziness and near-collapse following the bleed and required emergency review. He has ongoing abdominal discomfort related to a known ventral hernia and a history of ascites that has recently settled. He described significant thirst over the preceding 72 hours. There was no definitive report of melaena at the time of review, though there was a smell of melaena and haematemesis evident around the mouth on examination. He has had previous endoscopic surveillance and treatment for oesophageal varices.

Past Medical History:
 Alcohol-related liver cirrhosis - abstinent for approximately 9 months
 Known oesophageal varices (multiple, grade 2 on recent endoscopy)
 Partial portal vein thrombosis - longstanding, not anticoagulated
 Large ventral hernia - not for surgical management
 Recurrent ascites with previous spontaneous bacterial peritonitis episodes
 Hepatitis C (2019)
 COPD (2019)
 Drug-induced psychosis; detained under Section 2 (date not specified)
 Positive urine drug screen September 2025 for buprenorphine, THC, benzodiazepines and opiates; subsequently started on depot antipsychotic (zuclopenthixol)
 Mixed anxiety disorder and post-traumatic stress disorder
 Irritable bowel syndrome
 Most recent upper GI endoscopy 30 December 2025: two grade 2 oesophageal varices and portal hypertensive gastropathy without active bleeding recorded

Drug History:
 Nefopam 60mg PO tds PRN
 Senna 15mg PO nocte
 Furosemide 40-80mg PO each morning and 40mg PO at lunchtime
 Mirtazapine 15mg PO nocte
 Spironolactone 200mg PO morning and 100mg PO lunchtime
 Rifaximin 550mg PO bd (held)
 Propranolol 40mg PO bd
 Omeprazole 40mg PO bd (20mg x2 bd)
 Paracetamol 1g PO up to qds PRN
 Thiamine 100mg PO od

Recently Stopped Medications:
 Rifaximin 550mg PO bd - currently held

Social History:
 Lives independently; works as a support worker
 Mobile and ambulant; "gets around well"
 Alcohol: abstinent for approximately 9 months; one brief lapse lasting two days ~9 months ago
 Drug use: history of substance use with positive screen Sep 2025 (see PMH)

On Examination:
General: Unkempt, alert, haematemesis evident around the mouth; smell suggestive of melaena
Observations: Heart rate ~130 bpm (tachycardic); blood pressure 91/62 mmHg (low); oxygen saturations normal; respiratory rate within normal limits
Abdomen: Soft and non-tender on palpation; flank bulging; large ventral hernia present and dressed, not actively leaking ascites; no generalized abdominal distension apart from hernia
Cardiovascular: Heart sounds normal
Respiratory: Right basal crepitations; left chest clear
Neurological: No asterixis noted, no current evidence of overt hepatic encephalopathy on examination

Investigations:
 Haemoglobin: 93 g/L (previous 105 g/L on 17 February)
 INR: 1.3
 Venous blood gas: pH 7.47, lactate 6.6
 Sodium: 116 mmol/L
 Potassium: within normal range
 ALP: 143 U/L (reported as normal for this patient)
 Bilirubin: 17 (previous 8)
 AST: 54 U/L
 Amylase: within normal range
 CRP: 7 (previous 4)
 Chest X-ray: right basal changes; possible aspiration
 Prior upper GI endoscopy 30/12/2025: two grade 2 oesophageal varices and portal hypertensive gastropathy without active bleeding

Impression:
Variceal haematemesis secondary to decompensated alcohol-related liver disease with ascites. Acute kidney injury likely secondary to hypovolaemia/bleeding. No current clinical evidence of overt hepatic encephalopathy. Significant comorbidities influencing management include partial portal vein thrombosis and previous episodes of spontaneous bacterial peritonitis; not currently a TIPSS candidate.

Management Plan:
1. Resuscitation and monitoring: nil by mouth (sips to wet mouth only); continuous observations; fluid resuscitation for AKI as required.
2. Pharmacological haemostasis: continue IV terlipressin (as per local protocol).
3. Blood products and supportive therapy: human albumin solution to be administered (as per plan); monitor haemoglobin and transfuse if indicated.
4. Antibiotics: continue IV piperacillin/tazobactam (Tazocin) as per current prescription for possible aspiration and SBP coverage.
5. Laboratory monitoring: send ethanol level; recheck venous blood gas, lactate, full blood count and INR at 09:00; monitor INR and FBC closely.
6. Vitamin K: administer if INR >1.4.
7. Endoscopy: discuss with on-call endoscopist for urgent upper GI endoscopy +/- endoscopic therapy (banding/haemostasis) if further haematemesis or if indicated when stable. Consent obtained for endoscopy and possible general anaesthetic; patient informed of risks/benefits and high-risk nature of procedure.
8. Escalation: if further haematemesis, falling haemoglobin or rising lactate despite medical therapy, escalate to on-call endoscopist and consider interventional radiology for embolisation or TIPSS discussion (noting current contraindications/risks and prior encephalopathy).
9. Respiratory: chest x-ray reported right basal changes; treat suspected aspiration and monitor respiratory status.
10. Medication adjustments: rifaximin currently held; continue other chronic medications as appropriate and review diuretics given AKI and current status.
11. Follow-up: continue inpatient care under gastroenterology/hepatology; involve on-call endoscopist as required; outpatient follow-up in hepatology clinic after recovery.

Plan documented and discussed with patient; consent process for endoscopy started. Continue close observation and repeat investigations as above.

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Refined clerking (25 days ago 21:00)

Refined clerking Thu 12 March 2026 21:00

Last Modified: 25 days ago

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Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Acute upper gastrointestinal bleed in the context of decompensated alcohol-related liver disease.

History of Presenting Complaint:
Around 02:30 this morning the patient vomited fresh blood from the upper GI tract, followed by further vomiting with bright red material. He became dizzy and walked poorly, requiring assistance. He reports a history of known oesophageal varices and portal hypertension related to alcohol-related liver disease. He notes persistent thirst over the last 72 hours. He describes a large ventral hernia and longstanding ascites that has intermittently required diuretics. He reports an episode of coughing with haemoptysis-like features but primarily the concern is ongoing vomiting blood. There is no confirmed melaena; the patient is not tolerating oral intake and is currently NPO. On examination he is tachycardic with hypotension (BP 91/62) but saturations are acceptable at present. He has a soft, non-tender abdomen with a large ventral hernia; ascites is present but not currently leaking. There are right basal crepitations on chest exam; heart sounds are normal. There is evidence of hematemesis around the mouth and a foul/earthy smell suggestive of digested blood.

Past Medical History:
- Alcohol-related liver cirrhosis, abstinent for approximately 9 months
- Esophageal varices (grade 2, 2 episodes previously)
- Portal venous thrombosis (partial, long-standing; not anticoagulated)
- Large ventral hernia
- Spontaneous bacterial peritonitis risk with recurrent ascites; prior management not including TIPs due to concerns about hepatic encephalopathy
- Hepatitis C (2019)
- COPD (2019)
- Mixed anxiety and post-traumatic stress disorder; drug history with buprenorphine, benzodiazepines and opiates (past/ancestral use); depot antipsychotics (zuclopenthixol)
- Other historic conditions as per historical notes (not all details reproduced here)

Drug History:
- Propranolol 40 mg PO BD
- Omeprazole 20 mg PO BD
- Paracetamol 1 g PO PRN up to 4 times daily
- Thiamine 100 mg PO daily
- Senna 15 mg PO nocte
- Furosemide 40-80 mg PO in the morning and 40 mg PO at lunchtime
- Spironolactone 200 mg PO in the morning and 100 mg PO at lunchtime
- Rifaximin 550 mg PO BD (currently held)
- Amoxicillin/clavulanate or similar antibiotic course noted but exact dose unclear from transcription; medication held may be reviewed
- Depot zuclopentixol (antipsychotic) – following ongoing mental health management
- Several psychotropic substances historically noted; current status not detailed in this note

Recently Stopped Medications:
- Rifaximin currently held (as per transcription)

Allergy History:
- No drug allergies documented in transcription

Social History:
- Alcohol abstinent for approximately 9 months; prior heavy alcohol use with episodes of relapse
- Lives with carers; history of complex comorbidity requiring multidisciplinary care

On Examination:
- General: Alert but acutely ill due to GI bleed; tachycardic; hypotensive
- Vitals: BP 91/62; HR approximately 130 bpm; SpO2 normal on room air; RR not clearly documented; afebrile information not provided
- Abdomen: Soft and non-tender; large ventral hernia; ascites present but not currently distended; no clear abdominal tenderness
- Respiratory: Right basal crepitations; left side clear
- Cardiovascular: Regular heart sounds; peripheral pulses not detailed
- Neurological: No overt hepatic encephalopathy observed at this examination; no asterixis noted
- Other: Hematemesis evident around the mouth; odor suggestive of digested blood; no acute peritonitis signs described

Investigations:
- Venous blood gas (today): pH 7.47; lactate 6.6 mmol/L
- Full blood count: Hb 93 g/L (Feb 17: 105 g/L)
- INR: 1.3
- Sodium and potassium: within normal ranges
- ALP: 143 U/L (normal for patient)
- AST: 54 U/L
- Amylase: normal
- CRP: 7 mg/L (previously 4 mg/L)
- Bilirubin: 17 μmol/L (interpretation from transcription; exact value not explicitly dated)
- Urea/creatinine: not clearly stated in transcription
- Chest X-ray: Right basilar changes
- Abdominal ultrasound (recent): Non-occlusive portal vein thrombosis with stable appearances; no acute liver ultrasound changes emphasized
- Most recent upper GI endoscopy (30 December 2025): Esophageal varices grade 2 (two episodes noted); hypertensive changes without active bleeding
- Other imaging: Not specified beyond the above; endoscopy planned with consent
- Ethanol level: not yet performed; to be added to blood tests as per plan

Impression:
- Variceal upper GI bleed secondary to decompensated alcohol-related liver disease with portal hypertension, in the setting of ascites and a history of portal vein thrombosis
- Decompensated liver disease with AKI risk; no overt hepatic encephalopathy observed on examination
- Active management required including vasoactive therapy (terlipressin), IV fluids, antibiotics, and urgent endoscopic evaluation with potential tamponade/stent if endoscopy demonstrates active bleeding
- Ultrasound liver not pursued given recent ultrasound showing stable non-occlusive portal vein thrombosis
- Pain control and supportive care as part of ongoing management; consider escalation only if further bleeding occurs or labs worsen

Management Plan:
1. Continue terlipressin (epinephrine analogue) as per variceal bleeding protocol; monitor hemodynamics closely
2. Administer IV fluids for suspected AKI and maintain perfusion; continue albumin as clinically indicated (documented plan to give albumin today)
3. Administer antibiotics (piperacillin-tazobactam or equivalent) given suspected variceal bleed and cirrhosis; reassess based on culture/results
4. Vitamin K if INR exceeds 1.4; recheck INR, venous blood gas, and full blood count at 09:00; reassess Hb and lactate for response to therapy
5. Endoscopy: Obtain consent for an upper GI endoscopy ± therapeutic intervention (tamponade or stent placement) if active bleeding persists; assess feasibility of endoscopy under anesthesia if needed; discuss with on-call endoscopist
6. No oral intake (NPO) currently; allow mouth moistening only; discuss reintroduction of fluids when bleeding stabilizes
7. Imaging and monitoring: Chest X-ray findings reviewed; consider further imaging or ultrasound if indicated; ethanol level to be added to blood tests
8. Ongoing hematology/biochemistry monitoring with review by gastroenterology and hepatology teams; involve on-call endoscopist for potential urgent procedures if needed
9. Disposition: High-risk patient requiring transfer to an appropriate GI/hepatology bed with capability for endoscopy and critical care support if deterioration occurs; patient and family counselled regarding risks of endoscopic procedures and anesthesia, including potential complications and mortality risk
10. Documentation: Consent for endoscopy to be signed; ensure documentation of risks and benefits in line with institutional policy

Consent and Safety:
- Informed consent discussed for upper GI endoscopy with potential tamponade/stent and possible hepatic interventions; patient understands high-risk nature and potential complications of anesthesia and procedures; consent to be documented in the patient record

Follow-Up:
- To be reviewed in the gastroenterology/hepatology team after endoscopy results; plan to adjust therapy based on endoscopic findings and laboratory results

Additional Notes:
- Ethanol levels to be added to bloodwork; patient reported abstinence from alcohol for approximately 9 months with a previous brief relapse
- Documentation to reflect prior upper GI endoscopies and current plan for endoscopic management in the setting of cirrhosis and portal hypertension

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Refined clerking (25 days ago 21:05)

Refined clerking Thu 12 March 2026 21:05

Last Modified: 25 days ago

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Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Haematemesis

History of Presenting Complaint:
Presented with haematemesis starting at approximately 02:30. He reports vomiting fresh red blood and then feeling dizzy to the point that he could not walk. There is no clear history of melaena, although haematemesis was evident and he smelled of melaena on examination. He has had ongoing thirst for the last 72 hours.

He has background decompensated alcohol-related liver disease with ascites, known oesophageal varices and a partial non-occlusive portal vein thrombus. He has had treatment previously to reduce variceal bleeding risk. He also reports discomfort on passing urine and a cough. There has been no current evidence from the history of overt hepatic encephalopathy. He states he has not consumed alcohol for over 2 years, apart from a brief 2-day lapse in the more distant past.

Past Medical History:
• Alcohol-related liver cirrhosis with decompensation and recurrent ascites
• Large ventral hernia, not for surgical management
• Oesophageal varices, grade 2 on two occasions
• Partial longstanding portal vein thrombosis, not anticoagulated
• Drug-induced psychosis with detention under Section 2 Mental Health Act; positive for buprenorphine, THC, benzodiazepines and opiates in September 2025; subsequently commenced on depot antipsychotics
• Hepatitis C (2019)
• COPD (2019)
• Mixed anxiety disorder and post-traumatic stress disorder
• Irritable bowel syndrome
• Upper GI endoscopy (30/12/2025): two grade 2 oesophageal varices and portal hypertensive gastropathy without bleeding
• Multiple recent admissions with recurrent ascites and spontaneous bacterial peritonitis

Drug History:
• Nefopam 60mg PO TDS PRN
• Senna 15mg PO ON
• Furosemide 80mg PO mane and 40mg PO lunchtime
• Mirtazapine 15mg PO ON
• Spironolactone 200mg PO mane and 100mg PO lunchtime
• Co-trimoxazole 80/400mg PO BD
• Propranolol 40mg PO BD
• Omeprazole 40mg PO BD
• Paracetamol 1g PO QDS PRN
• Thiamine 100mg PO OD
• Zuclopenthixol depot injection

Recently Stopped Medications:
• Rifaximin 550mg PO BD - currently held due to concern regarding previous hepatic encephalopathy in the context of TIPS not being pursued

Social History:
Works as a support worker.
Ex-drinker, abstinent for approximately 9 months to over 2 years by history, with only a brief 2-day lapse reported previously.

On Examination:
General appearance: Unkempt. Haematemesis evident around the mouth. No overt hepatic encephalopathy clinically.
Observations:: HR 130, BP 91/62, oxygen saturations normal, respiratory rate normal
• Abdomen: Soft and non-tender. Flank bulging but no abdominal distension apart from a large ventral hernia. Dressing in situ and not currently leaking. Ascites present.
• Cardiovascular: Heart sounds normal.
• Respiratory: Right basal crepitations. Left chest clear.
• Neurological: No asterixis.
• Other: Smells of melaena.

Investigations:
• Urea: 11.6 from baseline 8.5
• Sodium: normal
• Potassium: normal
• ALP: 143, in keeping with baseline
• Bilirubin: 17 from 8
• Amylase: normal
• CRP: 7, previously 4
• AST: 54
• INR: 1.3
• Haemoglobin: 93, from 105 on 17/02/2026
• Venous blood gas: pH 7.47
• Lactate: 6.6
• Recent liver ultrasound: stable appearances of non-occlusive portal vein thrombus
• Chest X-ray: requested due to right basal changes, query aspiration

Impression:
Variceal bleed secondary to decompensated alcohol-related liver disease.
Secondary issues: Ascites, AKI, partial non-occlusive portal vein thrombus, right basal chest changes with possible aspiration, no current evidence of overt hepatic encephalopathy.

Management Plan:
1. Continue terlipressin.
2. Give IV fluid for AKI.
3. Administer human albumin solution.
4. Continue antibiotics.
5. Keep nil by mouth; allow mouth wetting only.
6. Monitor INR and full blood count.
7. Give vitamin K if INR rises above 1.4.
8. Repeat venous blood gas, full blood count and INR at 09:00.
9. If haemoglobin falls, lactate rises, or there is any further haematemesis despite terlipressin, discuss urgently again with the on-call endoscopist.
10. On-call endoscopist has been informed and is content with the current plan, but wishes to be re-contacted if there is further haematemesis or deterioration.
11. Proceed with upper GI endoscopy as indicated, with possible endoscopic treatment of bleeding, possible oesophageal stent placement for tamponade, and possible further intervention to reduce portal pressure if required.
12. Chest X-ray requested to assess right basal changes and possible aspiration.
13. Add ethanol level to blood tests.
14. No clear role for repeat liver ultrasound given the very recent ultrasound showing stable non-occlusive portal vein thrombus.

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Refined clerking (44 days ago 17:55)

Refined clerking Sat 21 February 2026 17:55

Last Modified: 44 days ago

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Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Haematemesis

History of Presenting Complaint:
Patient presented with episode of vomiting fresh red blood at 02:30 this morning. No melaena reported.

Further episodes with ambulance crew and ED team.

2x episodes with me at 18:15 - quite dark actually and not frank blood more altered blood with some flecks of food. Last eaten yesterday lunchtime.

Productive cough.

Past Medical History:
• Alcohol-related liver cirrhosis - abstinent for approximately 9 months
- Known oesophageal varices - 2 x grade 2
- Portal venous thrombosis - partial, not anticoagulated
- Hepatitis C (2019)
- Most recent upper GI endoscopy 30th December 2025: 2 times grade 2 oesophageal varices with portal hypertensive gastropathy without bleeding
- Multiple admissions with recurrent ascites - diuretic resistant, dependent on therapeutic paracentesis
• Large ventral hernia - not for surgical management
• Drug-induced psychosis - detention under Section 2 of Mental Health Act
- Currently on zuclopenthixol depot injection
- Mixed anxiety and post-traumatic stress disorder
- Positive toxicology for buprenorphine, THC, benzodiazepines and opiates (September 2025)
- Subsequently initiated on depot antipsychotics
• COPD (2019)

Drug History:
• Nefopam 60mg PO TDS PRN
• Senna 15mg PO ON
• Furosemide 80mg PO OM and 40mg PO lunchtime
• Mirtazapine 15mg PO ON
• Spironolactone 200mg PO OM and 100mg PO lunchtime
• Rifaximin 550mg PO BD (currently held)
• Co-trimoxazole 80/400mg PO BD
• Propranolol 40mg PO BD
• Omeprazole 40mg PO BD
• Paracetamol 1g PO QDS PRN
• Thiamine 100mg PO OD
• Zuclopenthixol depot injection

Allergy History:
Not documented in transcription

Social History:
Supported living
Alcohol: States abstinent for approximately 9 months
Previous substance misuse: Positive toxicology September 2025 for buprenorphine, THC, benzodiazepines and opiates.
Smoking: 15 per day for decades

On Examination:
General Appearance: Unkempt, evidence of haematemesis around mouth, smell of melaena noted.
Observations: HR 130bpm, BP 91/62mmHg, O2 saturations 96%, respiratory rate within normal limits, temperature not documented.
• Abdomen: Soft, non-tender. Flank bulging present but no abdominal distension apart from large ventral hernia. Hernia dressed, not currently leaking ascites.
• Cardiovascular: Heart sounds normal. Tachycardic at 130bpm.
• Respiratory: Right basal crepitations, left side clear.
• Neurological: No asterixis demonstrated. No current evidence of overt hepatic encephalopathy.

Investigations:
• Urea 116 (baseline 85)
• Sodium: Normal
• Potassium: Normal
• ALP 143 (normal for patient)
• Bilirubin 17 (from 8)
• Amylase: Normal
• CRP 7 (previously 4)
• AST 54
• INR 1.3
• Hb 93 (from 105 on 17th February 2026)
• Venous blood gas: pH 7.47, lactate 6.6
• Ethanol levels: Added on to blood tests
• Recent ultrasound liver: Stable appearances of non-occlusive portal vein thrombus

Impression:
Variceal bleed secondary to decompensated alcohol-related liver disease. 
Decompensated with ascites and acute kidney injury.
Possible right aspiration pneumonia

Management Plan:
1. Continue terlipressin IV for variceal bleeding at 1mg QDS initially
2. IV fluid resuscitation for AKI
3. Human albumin solution:  2 units today
4. Continue tazocin 
5. Chest X-ray given right basal changes and query aspiration
6. Monitor INR and full blood count - give vitamin K if INR >1.4
7. Recheck venous blood gas, full blood count and INR at 21:00 hours
8. Keep nil by mouth - can wet mouth with water
9. If further episode of haematemesis, Hb dropping, lactate rising following terlipressin: discuss with on-call endoscopist for urgent upper GI endoscopy +/- treatment of bleeding +/- oesophageal stent placement +/- TIPS procedure to decrease portal pressure - consented 
10. On-call endoscopist aware and happy with current plan, to be involved if further haematemesis or changes above
11. Allerton only
12. Septic screening with blood cultures, MSU +/- sputum MC+S
13. TEP as previously 
14. Add ethanol levels to bloods 
15. Suspend diuretics and beta blocker 
16. NRT

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• Safety-netting for variceal bleeding could be clearer - ensure patient understands to alert staff immediately if further vomiting or feeling faint
• Alcohol history exploration was appropriate but could have explored triggers for previous relapse and current support systems more thoroughly
• Escalation discussion regarding CPR/ITU appropriateness needs to be documented as discussed or completed urgently given high-risk clinical situation
• Chronic pain history well taken, but could have explored red flag symptoms more systematically (weight loss, change in bowel habit, nocturnal waking with pain)
• Excellent recognition of aspiration risk and appropriate chest X-ray request
• Could have been more explicit about monitoring frequency (hourly observations given unstable patient with tachycardia and hypotension)
• Good rapport building noted, but patient communication about nil by mouth status could have been clearer from outset to manage expectations
• Consider earlier involvement of palliative care team given advanced liver disease and repeated admissions for holistic management planning

Refined clerking (44 days ago 19:13)

Refined clerking Sat 21 February 2026 19:13

Last Modified: 25 days ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Haematemesis

History of Presenting Complaint:
Patient presented following episode of haematemesis at 02:30 hours. Vomited fresh red blood originating from upper gastrointestinal tract. Associated with severe dizziness preventing mobilisation. Patient reports persistent severe thirst over preceding 72 hours. Denies melaena. Reports ongoing cough. Patient has known oesophageal varices with previous treatment. Currently experiencing pain in lower abdomen relating to large ventral hernia. Reports dysuria, particularly severe with coughing. Patient reports alcohol abstinence for over 2 years with brief 2-day relapse approximately 9 months ago. No further alcohol consumption since.

Patient has ongoing upper abdominal pain since October 2024. Pain is constant, not associated with meals or other symptoms. Previous investigations including MRI, CT, ultrasound, upper GI endoscopy, blood tests and ECG have not identified cause. Trialled amitriptyline 10mg increasing to 20mg without benefit. Pain does not respond to codeine or tramadol. Patient describes pain as debilitating, affecting appetite.

Past Medical History:
• Alcohol related liver cirrhosis - abstinent approximately 9 months (with brief 2-day relapse)
• Large ventral hernia - not for surgical management
• Oesophageal varices - 2 times grade 2 (most recent endoscopy 30/12/2025)
• Portal venous thrombosis - partial, long standing, not anticoagulated
• Drug induced psychosis - detention under Section 2 Mental Health Act
• Substance misuse - positive for buprenorphine, THC, benzodiazepines and opiates (September 2025)
• Hepatitis C (2019)
• COPD (2019)
• Mixed anxiety and post traumatic stress disorder
• Irritable bowel syndrome
• Recurrent ascites - diuretic resistant, multiple admissions for spontaneous bacterial peritonitis
• Portal hypertensive gastropathy
• Not currently managed with TIPS due to concerns about previous hepatic encephalopathy

Drug History:
• Nefopam 60mg PO TDS PRN
• Senna 15mg PO ON
• Furosemide 80mg PO OM and 40mg PO lunchtime
• Mirtazapine 15mg PO ON
• Spironolactone 200mg PO OM and 100mg PO lunchtime
• Rifaximin 550mg PO BD - currently held
• Co-trimoxazole 80/400mg PO BD
• Propranolol 40mg PO BD
• Omeprazole 40mg PO BD
• Paracetamol 1g PO QDS PRN
• Thiamine 100mg PO OD
• Zuclopenthixol depot injection
• Terlipressin IV - commenced on admission
• Tazocin IV - commenced on admission

Allergy History:
NKDA

Social History:
Occupation: Support worker
Alcohol: Ex-drinker, abstinent over 2 years with brief 2-day relapse 9 months ago
Smoking: Not documented

On Examination:
General Appearance: Unkempt, evidence of haematemesis around mouth, smell of melaena
Observations: HR 130, BP 91/62, O2 saturations 100%, RR within normal limits, Temperature not documented
• Abdomen: Soft, non-tender, flank bulging but no abdominal distension apart from large ventral hernia which is dressed and not currently leaking ascites, no asterixis
• Respiratory: Right basal crepitations, left clear
• Cardiovascular: Heart sounds normal, tachycardic
• Neurological: No overt hepatic encephalopathy, no asterixis, appears sweaty

Investigations:
• Hb 93 (previous 105 on 17/02/2026)
• Urea 116 (baseline 85)
• Sodium: normal
• Potassium: normal
• ALP 143 (normal for patient)
• Bilirubin 17 (previous 8)
• Amylase: normal
• CRP 7 (previous 4)
• AST 54
• INR 1.3
• Venous blood gas: pH 7.47, lactate 6.6
• Ethanol levels: added on
• Chest X-ray: requested given right basal changes, query aspiration

Impression:
Variceal bleed secondary to decompensated alcohol related liver disease
Decompensated with ascites
Acute kidney injury
Active bleeding but no current evidence of overt hepatic encephalopathy

Management Plan:
1. Continue terlipressin IV for variceal bleeding
2. IV fluid for AKI
3. Human albumin solution - 3 units today, followed by 2 units
4. Continue tazocin
5. Chest X-ray given right basal changes, ? aspiration
6. Monitor INR and full blood count
7. Give vitamin K if INR greater than 1.4
8. Recheck venous blood gas, full blood count and INR at 09:00
9. If haemoglobin dropping, lactate rising or further episode of haematemesis following terlipressin, then for further discussion with on-call endoscopist
10. Discussed with on-call endoscopist - happy with current plan but to be involved if further episode of haematemesis or changes above
11. Upper GI endoscopy +/- treatment of bleeding +/- oesophageal stent placement +/- TIPS procedure to decompress portal system. If further haematemesis, urgent endoscopy under general anaesthesia in theatre. If no further haematemesis, endoscopy planned for tomorrow
12. No clear role of ultrasound liver given very recent ultrasound showing stable appearances of non-occlusive portal vein thrombus
13. Nil by mouth - patient may wet mouth with water but not swallow
14. Consent obtained for upper GI endoscopy including risks of further bleeding, perforation, failure to control bleeding, anaesthetic complications and death
15. Gastroenterology ward
16. Escalation plan to be documented
17. Follow-up outpatient appointment to address ongoing upper abdominal pain - consider trial of amitriptyline 30mg or alternative management for functional dyspepsia

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Summary:

Investigations:

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• Inadequate social history documentation - living situation, formal/informal care arrangements, and mobility/functional status not explored despite patient being a support worker
• Smoking history completely omitted - crucial in patient with COPD and multiple comorbidities
• Failed to document pack years or quantify previous alcohol consumption prior to abstinence - important for prognostication in liver disease
• Escalation plan discussed but not documented - critical safety-netting gap for high-risk patient with life-threatening GI bleed
• CPR and ITU status mentioned in plan but actual patient discussion/decision not recorded - essential medicolegal documentation missing
• Temperature not documented despite patient appearing unwell and on antibiotics for possible aspiration
• No documentation of patient understanding or concerns about serious diagnosis and high-risk procedures
• Chronic abdominal pain management appears rushed at end of consultation - this separate clinical issue deserves dedicated follow-up rather than brief mention during acute presentation
• Consider screening questions for hepatic encephalopathy more formally (orientation, concentration) rather than relying solely on asterixis examination

Patient Details

Issues review Tue 23 December 2025 11:37

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