Physician's Assistant

Refined clerking (87 days ago 06:08)

Refined clerking Fri 09 January 2026 06:08

Last Modified: 87 days ago

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Medical ST5 Miller Clerking

Presenting Complaint:
Diarrhoea and vomiting

History of Presenting Complaint:
81-year-old lady presenting with diarrhoea, vomiting and abdominal pain following recent antibiotic courses. Had three courses of nitrofurantoin for presumed UTI (though subsequent urine tests negative). Developed severe watery diarrhoea on 3rd January 2026 with abdominal cramps, reduced oral intake, nausea and retching producing thick white mucus. Constant abdominal pain without fever or rigors. GP prescribed metronidazole for suspected antibiotic-associated diarrhoea, buscopan, loperamide and antiemetics.

Initially had profuse watery diarrhoea for two nights (approximately 12 hours continuously), progressing to clear fluid then blood-stained stool. Has not opened bowels for 4 days but experiences severe cramping spasms throughout abdomen whenever eating or drinking. Lost over 10 pounds since illness onset (from 9 stone 3 to 8 stone 9). No vomiting currently but persistent nausea and weakness.

Background weight loss and difficulty swallowing large meals led to upper GI endoscopy and CT scan in December 2025 for investigation of possible malignancy.

Past Medical History:
• Rheumatoid arthritis - on methotrexate
• Hiatus hernia - large but not requiring surgical intervention
• Asthma - well controlled with inhaler
• Previous registered nurse
• Recent UTI investigations - multiple negative cultures

Drug History:
• Methotrexate 6 tablets weekly (Sundays)
• Thyroxine (dose as per GP records)
• Folic acid (with methotrexate)
• Rosuvastatin (statin)
• Gaviscon PRN
• Recently prescribed: Metronidazole, Buscopan, antiemetics
• Inhaler for asthma (rarely used)
• Previously on Lansoprazole (stopped on GP advice)

Recently Stopped Medications:
• Lansoprazole - stopped as can cause diarrhoea
• Loperamide - avoiding as per GP advice

Allergy History:
NKDA

Social History:
Lives alone in bungalow. Eldest daughter visiting daily for support.
Retired, previously registered nurse, also ran hotel and holiday flats.
Non-smoker. Minimal alcohol.
Independent with ADLs but struggling due to current illness and arthritis.
Health-conscious, predominantly vegetarian diet with fish.

On Examination:
General Appearance: Alert but appears unwell and dehydrated. Significant recent weight loss evident.
Observations: Not formally recorded
• Hands: Mild psoriatic arthritis changes, slight swelling right hand
• Cardiovascular: Heart sounds normal
• Respiratory: Clear chest
• Abdomen: Tender in left lower quadrant, no guarding. Bowel sounds present
• Other: No peripheral oedema

Investigations:
• ALP 342 (previously normal)
• ALT 349 (previously normal)
• Creatinine 71 (baseline)
• Total protein 55, Albumin 37, Bilirubin 21
• CRP 50 (previously <1 in October)
• Urea 4.8, electrolytes normal
• FBC: Low red cell count, no anaemia, no neutrophilia
• VBG: pH 7.41, Na 131, K 3.2, Lactate 0.6
• CT Thorax/Abdomen/Pelvis (21/12/2025): Stable lung nodules, small hepatic cyst, no liver lesions, normal biliary tree, moderate faecal loading with slow transit, no malignancy

Impression:
Antibiotic-associated diarrhoea with possible overflow component
Differential Diagnoses: C. difficile infection vs overflow diarrhoea secondary to chronic constipation
Background chronic constipation and recent weight loss under investigation

Management Plan:
1. IV fluid resuscitation - 1L over 4 hours
2. Plain abdominal X-ray to assess for faecal loading/obstruction
3. Stool culture for C. difficile and other pathogens when sample available
4. Continue metronidazole pending culture results
5. Continue antiemetics and antispasmodics
6. NBM initially, gradual reintroduction of diet as tolerated
7. Medical bed for observation and IV therapy
8. Escalation plan: Patient appropriate for CPR, consider ITU if deterioration

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Refined clerking (87 days ago 06:11)

Refined clerking Fri 09 January 2026 06:11

Last Modified: 87 days ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Diarrhoea and vomiting

History of Presenting Complaint:
81-year-old lady presented with one week history of diarrhoea and abdominal pain. Had received three courses of nitrofurantoin for presumed UTI, though patient states urine dips were negative.

On 3rd January, developed watery diarrhoea lasting 12 hours overnight with abdominal cramping. This continued for two nights with clear fluid passing progressing to blood-stained fluid.

Nausea associated with retching but without vomiting, particularly after eating or drinking.

Episodes of cramping and spasming pain occurred whenever attempting oral intake. No fever or rigors reported. GP prescribed metronidazole for suspected antibiotic-associated diarrhoea, along with buscopan, loperamide, dioralyte and antiemetics. Bowels not opened for 3 days prior to presentation. Significant weight loss from 9 stone 3 pounds to 8 stone 9 pounds over one week. Feeling dehydrated and weak.

Past Medical History:
• Hiatus hernia
• Psoriatic arthritis - on methotrexate
• Asthma
• Previous weight loss and dysphagia - investigated with upper GI endoscopy and CT scan
• Chronic constipation since childhood

Drug History:
• Methotrexate 6 tablets once weekly (Sundays)
• Thyroxine (dose as per GP records)
• Folic acid (taken with methotrexate)
• Rosuvastatin (statin)
• Gaviscon on prescription
• Salbutamol inhaler PRN
• Lansoprazole (recently stopped by GP)
• Recently completed: Nitrofurantoin (three courses), Metronidazole, Buscopan, Loperamide, Dioralyte, antiemetics

Allergy History:
• NKDA

Social History:
Lives alone in bungalow. Daughter visits daily providing support. Previous occupations include registered nurse (orthopaedic ward), hotel owner, farm owner, holiday flat proprietor, and community carer. Retired early. Non-smoker, minimal alcohol intake. Self-describes as "health freak". Mainly vegetarian diet - vegetables, small amounts of fish, cheese, eggs. No red meat consumption.

On Examination:
General Appearance: Alert, appears unwell and dehydrated. Significant weight loss evident.
Observations: Not formally recorded
• Hands: Mild psoriatic arthritis changes, slightly swollen right hand
• Cardiovascular: Heart sounds normal
• Respiratory: Chest clear
• Abdomen: Tenderness in left lower quadrant, bowel sounds present and normal

Investigations:
• FBC: Low red cell count, no anaemia, no neutrophilia
• U&Es: Urea 4.8, Creatinine 71 (baseline), Sodium and potassium normal
• LFTs: ALT 349 (previously normal), ALP 342 (previously normal), Total protein 55, Albumin 37, Bilirubin 21
• CRP: 50 (previously <1 in October 2025)
• VBG: pH 7.41, Sodium 131, Potassium 3.2, Lactate 0.6
• Other: Phosphate normal, Magnesium normal
• CT Thorax/Abdomen/Pelvis (12/01/2025): Several unchanged lung nodules, stable intrapulmonary lymph nodes, small hepatic cyst, no new liver lesions, normal biliary tree, grossly normal upper bowel, moderate faecal loading with slow transit constipation, no evidence of malignancy

Impression:
Overflow diarrhoea secondary to faecal impaction
Differential Diagnoses: Antibiotic-associated diarrhoea (C. difficile), Infectious gastroenteritis
Secondary issues: Chronic constipation, recent weight loss, hiatus hernia

Management Plan:
1. IV fluid resuscitation - 1 litre over 4 hours
2. Plain abdominal X-ray to assess for faecal loading and exclude complications
3. Stool culture if sample obtained (patient carrying specimen pot)
4. Consider disimpaction regimen if overflow diarrhoea confirmed
5. Continue antiemetics as required
6. Dietary advice - small frequent meals, adequate fluid intake
7. Medical ward admission for monitoring and treatment
8. Escalation plan to be discussed with patient regarding ceiling of care

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Refined clerking (87 days ago 06:15)

Refined clerking Fri 09 January 2026 06:15

Last Modified: 87 days ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Diarrhoea and abdominal pain

History of Presenting Complaint:
This 81-year-old lady presented with a one-week history of severe diarrhoea and abdominal pain following three courses of nitrofurantoin for presumed UTI. The illness began on 3rd January 2026 with all-night watery diarrhoea lasting approximately 12 hours, accompanied by severe abdominal cramping. She experienced associated nausea and retching, producing thick white mucus. The diarrhoea progressed to frank red blood by the end of the episode. She was unable to tolerate oral intake due to severe cramping with eating or drinking.

She has had no bowel movements for the past 4 days and continues to experience constant abdominal pain, particularly in the left lower quadrant, with spasms triggered by oral intake. She reports feeling dizzy and weak, with significant weight loss of 8 pounds since onset (from 9 stone 3 to 8 stone 9 pounds). No fever or systemic illness reported.

The patient was treated by her GP with metronidazole for suspected antibiotic-associated diarrhoea, along with buscopan and antiemetics. She has been prescribed loperamide but has not taken it.

Past Medical History:
• Rheumatoid arthritis - on methotrexate
• Hypothyroidism
• Hiatus hernia - large but not requiring surgical intervention
• Asthma - well controlled
• Chronic constipation since childhood
• Previous three episodes of bronchitis
• COVID-19 - mild illness
• Previous career as registered nurse

Drug History:
• Levothyroxine 100mcg PO OD
• Methotrexate 20mg PO weekly (Sundays)
• Folic acid 5mg PO daily (except methotrexate days)
• Rosuvastatin 5mg PO OD
• Famotidine 20mg PO as directed
• Gaviscon Advance 5-10ml PO QDS
• Fostair inhaler 2 puffs BD via spacer
• Salamol inhaler 2 puffs PRN
• Oxybutynin 2.5mg PO BD
• Laxido sachets PRN

Recently Stopped Medications:
• Loperamide - prescribed but patient chose not to take
• Lansoprazole - recently discontinued

Allergy History:
NKDA

Social History:
Lives independently in a bungalow. Widowed with supportive eldest daughter visiting daily. Previous occupations include nursing, hotel management, farming, and property investment. Retired early. Non-smoker, minimal alcohol consumption. Describes herself as a "health freak" with predominantly vegetarian diet rich in vegetables, some fish, cheese, and eggs. No red meat consumption.

On Examination:
General Appearance: Alert, appears well but concerned about weight loss
• Hands: Minimal psoriatic arthritis changes, slight swelling right hand
• Cardiovascular: Heart sounds normal
• Respiratory: Chest clear, no acute distress
• Abdomen: Tender in left lower quadrant, described as constantly sore but not spasming. Bowel sounds audible

Investigations:
• ALP 342 (previously normal)
• Creatinine 71 (baseline)
• Sodium and potassium normal
• ALT 349 (previously normal)
• Total protein 55, Albumin 37, Bilirubin 21
• CRP 50 (previously <1 in October)
• Urea 4.8, phosphate and magnesium normal
• FBC: Low red cell count but no anaemia, no neutrophilia
• VBG: pH 7.41, Na 131, K 3.2, Lactate 0.6
• CT Thorax/Abdomen/Pelvis (12/12/2025, reported 08/01/2026): Unchanged lung nodules and intrapulmonary lymph nodes, stable small hepatic cyst, no new liver lesions, no significant biliary tree abnormality, grossly normal upper bowel appearance, moderate faecal loading with slow transit constipation, no evidence of malignancy

Impression:
Slow transit constipation with possible overflow diarrhoea
Differential Diagnoses: Antibiotic-associated diarrhoea vs C. difficile infection vs overflow diarrhoea secondary to chronic constipation
Secondary issues: Significant weight loss requiring nutritional support, hiatus hernia affecting oral intake

Management Plan:
1. Plain abdominal X-ray to assess current constipation status
2. IV fluid therapy - 1 litre over 4 hours for rehydration
3. Stool culture if specimen available to exclude infectious cause
4. Continue current antibiotic course as prescribed by GP
5. Nutritional support and dietitian review for weight management
6. Review constipation management - optimise Laxido usage
7. Medical admission for observation and symptom management
8. Patient suitable for full active treatment including CPR if required

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Refined clerking (87 days ago 06:15)

Refined clerking Fri 09 January 2026 06:15

Last Modified: 87 days ago

MRN:

Content:

Medical ST5 Miller Clerking
09/01/2026 06:20

Presenting Complaint:
Diarrhoea and vomiting

History of Presenting Complaint:
81-year-old lady presented with one week history of diarrhoea and abdominal pain. Had received three courses of nitrofurantoin for presumed UTI, though patient states urine dips were negative.

On 3rd January, developed watery diarrhoea lasting 12 hours overnight with abdominal cramping. This continued for two nights with clear fluid passing progressing to blood-stained fluid.

Nausea associated with retching but without vomiting, particularly after eating or drinking.

Episodes of cramping and spasming pain occurred whenever attempting oral intake. No fever or rigors reported.

GP prescribed metronidazole for suspected antibiotic-associated diarrhoea, along with buscopan, loperamide (she is not taking this), dioralyte and antiemetics. Bowels not opened for 3 days prior to presentation. Significant weight loss from 9 stone 3 pounds to 8 stone 9 pounds over one week. Feeling dehydrated and weak.

Past Medical History:
• Psoriatic arthritis - on methotrexate 20mg weekly
• Acquired hypothyroidism
• Hiatus hernia
• Gastric dysmotility (July 2025)
• Asthma
• Chronic kidney disease stage 3
• Age-related macular degeneration
• Cataracts - both eyes
• Gilbert syndrome

Drug History:
• Levothyroxine 100mcg PO OD
• Methotrexate 20mg PO weekly (Sundays)
• Folic acid 5mg PO OD (except methotrexate day)
• Rosuvastatin 5mg PO OD
• Famotidine 20mg PO OD
• Gaviscon Advance 5-10ml QDS
• Fostair inhaler 100/6mcg 2 puffs BD via spacer
• Salbutamol inhaler 2 puffs PRN
• Oxybutynin 2.5mg PO BD
• Laxido sachets PRN
• Colpermin capsules TDS PRN

Allergy History:
NKDA

Social History:
Lives alone in bungalow. Daughter visits daily. Independent with activities of daily living normally. Ex-registered nurse, previously ran hotel and holiday flats. Non-smoker. Minimal alcohol.

On Examination:
• Abdomen: Soft, tender left iliac fossa, bowel sounds present
• Cardiovascular: Heart sounds normal, no murmurs
• Respiratory: Clear chest, no wheeze
• Other: Mild psoriatic arthritis changes in hands

Investigations:
• ALP 342 (previously normal)
• ALT 349 (previously normal)
• Creatinine 71 (baseline)
• Albumin 37, Total protein 55
• Bilirubin 21
• CRP 50 (previously <1 in October 2025)
• Urea 4.8
• FBC: Low red cell count, no anaemia, no neutrophilia
• VBG: pH 7.41, Na 131, K 3.2, lactate 0.6
• CT Thorax/Abdomen/Pelvis (12th December 2025): Stable lung nodules, small hepatic cyst, normal biliary tree, moderate faecal loading consistent with constipation/slow transit, no evidence of malignancy

Impression:
Timeline of diarrhoea with raised inflammatory markers makes antibiotic-associated diarrhoea or C. difficile a possibility
- Unless there is a significant complication I would not expect her not to open bowels for 3 days with this though
- Clinically I don't think a complication is very likely
Possibly overflow diarrhoea
- Unclear cause of raised inflammatory markers in that context

Management Plan:
1. IV fluids
2. Plain abdominal X-ray to assess for faecal loading and exclude complications
3. Stool culture and C. difficile toxin
4. Continue current antibiotics and symptomatic treatment
5. Bowel chart
6. Dietetic review for nutritional support given significant weight loss
7. AMU
8. TEP: Full escalation

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Refined clerking Fri 09 January 2026 06:08

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Refined clerking Fri 09 January 2026 06:15

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