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Patient Details

Refined clerking (89 days ago 00:59)

Refined clerking Wed 07 January 2026 00:59

Last Modified: 89 days ago

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Medical ST5 Miller Clerking
07/01/26 01:00

Presenting Complaint:
Dysphagia and pain

History of Presenting Complaint:
This 80-year-old gentleman presents with his fourth presentation of pain and difficulty swallowing associated with his oesophageal stent inserted on 29/12/2025. He reports progressive worsening of dysphagia since discharge on 05/01/2026 following recent admission to Allerton Ward.

Currently unable to tolerate solid food and minimal liquid intake - only managing sips of protein drinks before experiencing mild pain and stops eating after this. Describes pain in upper abdomen/lower chest, triggered by attempting to swallow more than small sips. Pain is not severe when it occurs but creates significant anxiety about swallowing. Ice cream appears to be better tolerated than liquids. No intake today. Not tried any solids since stent.

Reports 9kg weight loss (from 12 stone 4lbs to 8 stone 12lbs) but weight has stabilised recently.

Collateral history from wife indicates significant mood swings and carer stress. Wife contacted GP on 06/01/2026 stating she was "at her wit's end" with patient not eating or drinking, resulting in ambulance call.

Due to see oncologist on 14/01/2026 to discuss palliative chemotherapy options.

Past Medical History:
• T4N3M1 oesophageal poorly differentiated adenocarcinoma involving oesophagus and stomach with metastatic nodal disease above and below diaphragm (2025)
• Monoclonal gammopathy of uncertain significance (October 2025)
• TIA (April 2025)
• Rosacea (June 2023)
• Angioedema
• Balanitis
• Hypertension (2014)
• Gout (2014)

Drug History:
• Mometasone nasal spray
• Lansoprazole 30mg PO BD
• Aspirin 75mg PO OD
• Orajel mouth gel PRN
• Hydroxycobalamin injections
• Laxido PRN
• Viscotears PRN
• Atenolol 25mg PO OD
• Oramorph PRN (struggling to take due to swallowing difficulties)
• Paracetamol liquid (Calpol) - currently managing pain

Allergy History:
NKDA

Social History:
Lives at home with wife who is his primary carer. Wife experiencing carer stress and has contacted social services for support.

On Examination:
Dehydrated
• Cardiovascular: Heart sounds normal, no peripheral oedema. Reduced skin turgor and dry mucous membranes
• Respiratory: Chest clear, reduced chest expansion noted
• Abdomen: Epigastric tenderness, no other abnormalities detected
• ENT: White residue and coating on tonsils and tongue consistent with oropharyngeal candidiasis

Investigations:
• Chest X-ray (04/01/2026): Stent in situ, no interval change, no complications
• CRP: Initially 177, improved to 86 without intervention
• Neutrophils: 8.49 (elevated)
• White cell count: Normal
• LFTs: Normal
• Creatinine: Peaked at 123 during admission, improved to 82 at discharge
• Urine MC&S: No bacterial growth
• CT Thorax/Abdomen (December 2025): Progressive supraclavicular mediastinal lymphadenopathy, no stent complications

Impression:
Multifactorial dysphagia:
1. Oropharyngeal and probable oesophageal candidiasis
2. Psychological difficulties around swallowing secondary to stent-related pain
3. Stent-related discomfort and reflux
Dehydration secondary to poor oral intake
Social concerns with minimal intake at home and carer stress

Management Plan:
1. IV access and IV fluids
2. Chest X-ray to confirm stent position - although displacement seems v unlikely
3. Blood tests including inflammatory markers
4. Nystatin oral suspension for oropharyngeal candidiasis
5. Fluconazole to treat presumed oesophageal candidiasis antifungal treatment
6. Trial of ice cream and encourage small frequent intake
7. Speech and language therapy referral for swallowing assessment
8. Brief admission primarily for social reasons
9. Allerton

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Refined clerking Wed 07 January 2026 00:59

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