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Patient Details

Refined clerking (88 days ago 05:28)

Refined clerking Thu 08 January 2026 05:28

Last Modified: 88 days ago

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Medical ST5 Miller Clerking
08/01/2026 07:15

Presenting Complaint:
Fall and feeling generally unwell

History of Presenting Complaint:
This 62-year-old man has been feeling generally unwell for several months, describing feeling "crap", drained and washed out. Over the last few days he has felt worse. Today he fell off a chair at home but did not lose consciousness and does not believe he hit his head. CT head shows no acute intracranial findings.

He has been reducing his alcohol intake recently as he has been feeling so unwell and "wants to continue living". He has been seeing his GP for leg ulcers and wound management of his right lower leg with associated leg swelling. Was admitted in October 2025 with leg swelling secondary to amlodipine, AKI, and electrolyte disturbances including hyponatraemia and hypokalaemia.

Past Medical History:
• Asthma
• Hypertension
• Osteoarthritis
• Leg ulcers with wound management
• Previous admission October 2025 - leg swelling secondary to amlodipine, AKI, electrolyte disturbances

Drug History:
• Gabapentin 300mg PO TDS
• luforbec inhaler 100/6 micrograms
• Co-codamol 30/500mg PO 1-2 tablets QDS PRN

Allergy History:
NKDA

Social History:
Lives alone at home. Works as a lorry driver and chef, last worked 3-4 weeks ago. Ex-smoker of 20 cigarettes per day for 20 years, stopped 20 years ago. Heavy alcohol intake - drinks 8-10 cans of export strength lager (7%) daily, has been drinking at this level since age 16. Recently reducing intake due to feeling unwell. Sometimes drinks in the morning but not when driving apparently - I must say I doubt this given his alcohol dependence picture currently.

On Examination:
Unwell, a little confused
• Abdomen: Soft, non-tender, bedside USS: Nodularb liver edge. Small GB stone. Otherwise nil seen. Adverse adiposity to assess splenomegaly
Fine tremor of hands consistent with alcohol withdrawal. Asterixis
Spider naeviae
• Cardiovascular: Regular heart sounds, good peripheral pulses, bilateral lower limb oedema extending to hips
• Respiratory: Clear chest examination anteriorally
• Other: Small clean ulcer on right lower leg, healed ulcer on left leg.

Investigations:
• CT Head: No acute intracranial findings, left medial pterygoid plate changes likely chronic or anatomical variation
• Creatinine 210 (baseline 80)
• Potassium 2.8
• Sodium 126 (previously 134 on 04/12)
• ALP 144
• ALT 39
• Albumin 27
• Bilirubin 45
• Protein 58
• CK 847
• CRP 3
• Urea 7.3
• AST 107
• Hb 95 (previously 118 in October 2025)
• MCV 119.7
• Platelets 154
• RDW 17.4
• Neutrophils 6.16
• WCC 7.4
• VBG: pH 7.33, hypochloraemia 84, ionised calcium 0.93, glucose 3, lactate 9.6
• Wound swab (12/11/2025): Heavy growth Pseudomonas aeruginosa
• Ultrasound liver: Gallbladder with small stone, liver appears modular and inflamed

Impression:
First presentation of decompensated alcohol-related liver disease with significant metabolic derangement and acute kidney injury
Alcohol withdrawal and dependence, 
Possibly infected leg ulcer
Macrocytosis secondary to alcohol use

Management Plan:
1. Replace electrolytes IV - magnesium, phosphate, calcium
2. Input/output monitoring, catheterise
3. Formal ultrasound liver and KUB [/]
4. Add INR to bloods [/], consider vitamin K if INR > 1.4 
5. CIWA
6. IV Vitamins
7. Non-invasive liver screening [/]
8. Repeat leg wound swab
9. BNP [/] +/- echocardiogram given oedema
10. Alcohol cessation support and alcohol care team referral
11. Allerton ward
12. TEP Full escalation
13. Chest X-ray, MSU for septic screening

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Refined clerking Thu 08 January 2026 05:28

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