Physician's Assistant

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Content:

Medical ST5 Miller Clerking
08/01/2026 21:30

Presenting Complaint:
Jaundice, weight loss and abdominal distension

History of Presenting Complaint:
This 45-year-old gentleman presented with a several week history of progressive abdominal distension, weight loss and jaundice.

Symptoms began around Christmas time with breathlessness and early satiety.

He developed significant abdominal swelling causing him to reduce food intake to yoghurts and fruit. He noticed jaundice approximately one week prior to admission when pointed out by his GP. He stopped drinking alcohol completely 5 days prior to admission after daily consumption for several years.

Dry cough with minimal sputum production and constipation. He temporarily stopped his diabetic medications due to concerns about stomach upset but has since recommenced them.

Past Medical History:
• Type 2 diabetes mellitus (November 2025)
• Alcohol dependence (coded December 2025)

Drug History:
• Metformin 1g PO BD
• Sitagliptin 100mg PO OD

Allergy History:
• NKDA

Social History:
Lives alone in converted caravan within farm barn. 
Has worked on dairy farm for 9 years, previously worked in Cornwall. 
Has one brother living locally. 
Alcohol dependence - approximately half bottle of rum (20 units) daily mixed with Fanta Zero for several years (140 units per week) until stopping completely 5 days prior to admission. Previously weekend drinking only but escalated to daily consumption over past few years. Non-smoker.

On Examination:
In fit to sit
General appearance: Alert, slightly jaundiced, appears unwell
• Abdomen: Grade 3 ascites. no spider naeviae or palmar erythema
• Cardiovascular: Heart sounds normal, dry MMs
• Respiratory: left basal crepitations
• Bedside USS: Smooth liver edge, large volume, steatotic. Moderate ascites present in bilateral iliac fossae

Investigations:
• Hb 116
• WCC 14
• Neutrophils 10.8
• Creatinine 81
• ALP 182
• ALT 42
• Bilirubin 202 (previously 177 on 05/01, 50 on 09/12)
• CRP 69
• AST 95
• Venous blood gas: pH 7.46, Na 126, K 3.4, glucose 13.2
• Ascitic tap performed: Fluid sent for cell counts, MC&S, cytology and chemistry and awaited

Impression:
Alcohol-related hepatitis
Decompensated alcohol and metabolic-related (MetARLD) liver disease with ascites only
Likely left lower zone pneumonia, Type 2 diabetes mellitus, recent alcohol cessation

Management Plan:
1. Move to bedspace please - 30-day mortality circa 20% with AR Hep
2. Ascitic tap results awaited - if SBP, commence HAS
3. IV antibiotics (Tazocin) for pneumonia in context of liver disease
4. Pabrinex for 3 days (thiamine replacement)
5. Add INR to blood tests, vitamin K if deranged
6. Chest X-ray and MSU
7. Alcohol care team review, CIWA
8. Allerton
9. TEP: Full escalation
10. Once infection treated and SBP excluded, start 100mg Spironolactone

Summary:

Investigations:

Patient Details

Refined clerking Thu 08 January 2026 22:56

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