Physician's Assistant

Patient Details

Refined clerking (41 days ago 10:06)

Refined clerking Tue 24 February 2026 10:06

Last Modified: 41 days ago

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Medical ST5 Miller Clerking
Date: 26/02/2024 10:06

Presenting Complaint:
Haematemesis

History of Presenting Complaint:
A 58-year-old lady presented following an acute episode of haematemesis in the early hours of this morning. She reported vomiting bright red blood on approximately four occasions in quick succession, with no significant interval between episodes. She estimated the volume to be approximately two litres in total, describing it in terms of a large ice cream container. The episode occurred at approximately 03:00 this morning.

She reported a background of chronic nausea, which she attributes to her medication regimen, particularly metformin and sertraline in combination. She does not tolerate tablets well and frequently vomits after taking them with liquid. She reported no haematochezia or melaena. She has been mildly constipated over the past week, though this appears to be resolving.

She disclosed a longstanding and significant alcohol history, drinking most evenings, having previously consumed up to a bottle of spirits per day over a period of decades. She does not drink in the mornings. On examination, she appeared tremulous and diaphoretic, which is consistent with early alcohol withdrawal in the context of reduced oral intake and vomiting. She lives alone with her elderly father, for whom she is the sole carer, and this significantly delayed her presentation.

Past Medical History:
• Osteoarthritis of the hip — referred for hip replacement (July 2025)
• Type 2 diabetes mellitus (2022) — latest HbA1c: Unknown
• Asthma — latest spirometry: Unknown
• Migraine
• Hypertension

Drug History:
• Bempedoic acid 180mg PO OD
• Metformin modified-release 500mg PO BD (with breakfast and evening meal)
• Candesartan 16mg PO BD
• Sertraline 100mg PO OD
• Amlodipine 10mg PO OD

Recently Stopped Medications:
None documented.

Allergy History:
Not documented — to be clarified.

Social History:
Living situation: Lives in a house with her elderly father, who has significant care needs. Stairs present within the property.
Mobility: Uses a wheeled walker (Zimmer frame with four wheels). Unable to mobilise outside the house due to hip and knee pathology. Unable to drive.
Carers: Provides 24-hour care for her father. Formal care arrangements in place: morning carer and afternoon carer. A friend is currently covering care responsibilities during this admission. Rapid response support is available 10:00–19:00, with a gap between 07:00 and 10:00.
Occupation: Full-time informal carer for her father.
Smoking: Not documented.
Alcohol: Longstanding history of significant alcohol use. Previously consuming up to a bottle of spirits per day over several decades. Currently drinking most evenings, reduced from previous levels. Drinks in the evening only; does not drink in the mornings.
Functional Status: Significantly limited by hip and knee osteoarthritis. Housebound. Unable to manage stairs easily. Requires walking aid at all times.

On Examination:
General Appearance: Visibly unwell. Tremulous. Diaphoretic. Anxious.
Observations: HR 109 bpm, BP 149/94 mmHg, RR 18, O2 sats: not documented, Temperature: not documented.
• Abdomen: Bedside ultrasound performed — liver appeared echogenic, in keeping with hepatic steatosis. Gallbladder visualised with a small calculus noted, thought to be incidental. No ascites identified on bedside assessment.
• Cardiovascular: Spider naevi noted on the chest. Palmar erythema present bilaterally. Peripheral pulse noted to be present.
• Respiratory: Not formally documented.
• Neurological: Jaw tremor noted. Tremulousness present. Consistent with early alcohol withdrawal.
• Other: Copper staining noted to the finger where a ring is usually worn.

Investigations:
• PT: 51.1 seconds
• Prothrombin time: 23 seconds
• INR: 1.6
• Fibrinogen: 1.7 g/L
• APTT ratio: 1.29
• Venous blood gas lactate: 4.8 mmol/L
• Hb: 74 g/L (previously 97 g/L in December 2021)
• Urea: 2.2 mmol/L
• Renal function: Normal
• Bilirubin: 23 umol/L
• Albumin: 33 g/L
• ALT: 56 U/L
• AST: 124 U/L
• CRP: 3 mg/L
• Full blood count: Awaited
• Amylase: Awaited
• Bedside ultrasound liver (26/02/2024): Echogenic liver in keeping with hepatic steatosis. Small gallstone noted. No ascites identified.

Impression:
First presentation of decompensated alcohol-related liver disease.
Differential Diagnoses: Oesophageal variceal haemorrhage secondary to portal hypertension; oesophagitis with upper GI bleeding.
Secondary Issues: Clinical evidence of portal hypertension (spider naevi, palmar erythema). Coagulopathy on bloods. Possible early alcohol withdrawal (tremor, diaphoresis). Anaemia secondary to acute upper GI haemorrhage. Hepatic steatosis on bedside ultrasound. Incidental gallstone.

Management Plan:
1. Monitoring: Continuous monitoring of haemodynamic observations. Repeat venous blood gas and repeat glucose measurement. Monitor haemoglobin — if dropping, consider further transfusion (1 unit packed red cells currently being transfused for Hb 74 g/L).
2. Investigations: Await full blood count, amylase, and inflammatory markers. Formal liver ultrasound (radiology department) to formally assess liver architecture and portal vasculature. ECG (12-lead tracing of heart). Blood cultures, MSU, and chest X-ray to complete septic screen.
3. Treatment:
 a. IV fluid resuscitation.
 b. Alcohol withdrawal care: Chlordiazepoxide reducing regimen.
 c. IV Pabrinex (thiamine/vitamin B complex) for alcohol-related nutritional deficiency.
 d. Vitamin K 10mg IV OD for 3 days (for coagulopathy).
 e. IV Tazocin (piperacillin/tazobactam) — IV antibiotics to cover infective risk associated with variceal bleeding.
 f. Proton pump inhibitor — given possible underlying oesophagitis as a contributing cause of bleeding.
 g. Nutritional supplementation — to address protein and nutritional deficiencies; to be arranged on the ward.
 h. If further episode of haematemesis: Terlipressin 2mg IV, and urgent discussion with on-call endoscopist.
4. Procedures: OGD to be arranged for tomorrow given evidence of upper GI bleeding with likely oesophageal varices.
5. Patient Education: Extensive discussion held with the patient regarding the likely diagnosis of alcohol-related liver cirrhosis and the significant prognostic impact of continued alcohol use. Patient was counselled that continued alcohol use is associated with a 50% mortality at two years, whereas abstinence is associated with 80% survival at ten years. Patient appeared to understand and engage with this information. Alcohol support services to be arranged during the inpatient stay.
6. Referrals: Gastroenterology/hepatology inpatient team. Endoscopy team for OGD. Alcohol liaison/support services. Social work review given complex caring responsibilities at home.
7. Admission: Allerton Ward (liver/gastroenterology ward). Patient may initially be admitted to the Acute Medical Unit pending bed availability on the ward.
8. Escalation: Full escalation as first presentation — patient is for CPR and full active management at this time. To be monitored closely overnight.

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Refined clerking (43 days ago 20:02)

Refined clerking Sun 22 February 2026 20:02

Last Modified: 43 days ago

MRN:

Content:

Medical ST5 Miller Clerking
22/02/2026 20:02

Presenting Complaint:
Haematemesis

History of Presenting Complaint:
A 58-year-old lady presented following an episode of haematemesis in the early hours of this morning. She reported vomiting approximately four times in quick succession, with each episode producing a significant volume of bright red blood — estimated at approximately two litres in total. She did not seek medical attention overnight as she is the sole carer for her father and was reluctant to leave him; she also noted the bleeding had appeared to settle spontaneously.

No melaena. Bowels last opened yesterday - brown.

On direct questioning, she disclosed a longstanding history of significant alcohol use, drinking most evenings, with a previous history of drinking up to a bottle per day for several decades. She reported she had reduced her intake more recently. On examination, she appeared tremulous and diaphoretic, raising concern for early alcohol withdrawal in the context of being unable to drink following haematemesis.

She was noted to have a background of osteoarthritis of the hip awaiting replacement, which significantly limits her mobility and independence.

Past Medical History:
• Osteoarthritis of the hip — awaiting hip replacement (referred July 2025)
• Type 2 diabetes mellitus (diagnosed 2022)
• Asthma
• Migraine
• Hypertension
• Alcohol-related liver disease — first presentation (this admission)

Drug History:
• Bempedoic acid 180mg PO OD
• Metformin modified-release 500mg PO with breakfast and 500mg PO with evening meal
• Candesartan 16mg PO BD
• Sertraline 100mg PO OD
• Amlodipine 10mg PO OD

Allergy History: no
NKDA

Social History:
Lives in a house with her father, for whom she provides 24-hour care.
Mobilises with a wheeled walker indoors. Unable to manage stairs due to painful hip (AVN). Housebound
Longstanding history of alcohol use. Previously drinking up to a bottle of wine per day for several decades. More recently drinking most evenings, typically one to two glasses of wine. Not drinking in the mornings.

On Examination:
Unwell-appearing lady, tremulous and diaphoretic.
Observations: HR 109, BP 149/94, RR 18, SpO2 98%
• Abdomen: Bedside ultrasound performed — liver appears echogenic, consistent with hepatic steatosis. Gallbladder visualised with a small calculus, unlikely to be clinically significant. No ascites identified. Splenomegaly.
• Cardiovascular: Palmar erythema. Spider naevi visible on the chest, consistent with portal hypertension.
• Respiratory: Clear chest
• No peripheral oedema

Investigations:
• PT 51.1 seconds
• Prothrombin time 23 seconds
• INR 1.6
• Fibrinogen 1.7
• APTT ratio 1.29
• Venous blood gas lactate 4.8
• Hb 74 — previously 97 in December 2021

Impression:
First presentation of decompensated alcohol-related liver disease with GI bleeding
- Clinical evidence of portal hypertension (spider naevi, palmar erythema, splenomegaly) and upper GI bleeding, from varices or oesophagitis 
- Coagulopathy
Early alcohol withdrawal

Management Plan:
1. Repeat venous blood gas now, monitor haemoglobin x2 overnight - if dropping, consider further transfusion (one unit of packed red cells already transfused for Hb 74).
2. Formal liver ultrasound scan; ECG; blood cultures and MSU to complete septic screen; CXR
3. Medications:
   a. IV fluids for resuscitation and maintenance
   b. Pabrinex
   c. Chlordiazepoxide
   d. Vitamin K 10mg IV OD for 3 days
   e. IV Tazocin
   f. Proton pump inhibitor — to cover possible underlying oesophagitis
   g. If further haematemesis: Terlipressin 2mg IV and urgent discussion with on-call endoscopist
   h. Nutritional supplementation
4. OGD mane if stable - NBM
5. Detailed discussion held with patient regarding the likely diagnosis of alcohol-related liver cirrhosis, the significant mortality risk of continued alcohol use and the markedly improved prognosis with abstinence. Patient was counselled on the importance of complete alcohol abstinence.
6. ACT
7. Allerton Ward only (Via AMU if required)
8. Full escalation

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Summary:

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