Physician's Assistant

Patient Details

Refined clerking (45 days ago 14:03)

Refined clerking Fri 20 February 2026 14:03

Last Modified: 45 days ago

MRN:

Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Melaena

History of Presenting Complaint:
This 58-year-old lady presented with a 2-week history of black tarry stools. The melaena started approximately 2 weeks ago, stopped briefly, then recurred. Over the last few days she had been feeling increasingly weak and short of breath. She denies chest pain, abdominal pain, nausea or haematemesis.

She is currently taking Apixaban following vascular surgery. Her last dose was taken yesterday at approximately 22:00-23:00. She denies use of NSAIDs or steroids.

Her mobility has been severely limited for approximately 2 years prior to her vascular surgery due to leg pain. She lives in a flat with steps and has been largely housebound as there are no railings to assist her. She reports being unable to manage stairs easily.

She has a significant alcohol history, consuming 1-1.5 litres of cider daily for approximately 20 years. This stopped approximately 5-10 years ago but timeline is unclear.

Past Medical History:
• Vascular surgery - Right axillo-bifemoral bypass graft for bilateral lower limb ischaemia (October 2025)
• Distal phalanx osteomyelitis with collection (October 2025)
• Acute and chronic back pain - known to spinal team in Exeter, awaiting spinal root injection
• Spinal stenosis (coded August 2024)
• Non-diabetic hyperglycaemia
• Anxiety and depression
• Alcohol excess (coded 2002)
• Angular dermatitis (coded 2000)

Drug History:
• Apixaban 2.5mg PO BD
• Aspirin 75mg PO OD
• Lansoprazole 30mg PO OD
• Duloxetine 60mg PO OD
• Pregabalin (dose unclear) PO (frequency unclear)
• Promethazine 25-50mg PO Nocte
• Colecalciferol 1000 units PO OD
• Metronidazole gel topical PRN

Allergy History:
NKDA

Social History:
Lives alone in a flat with steps. 
Housebound for approximately 2 years prior to October 2025 vascular surgery due to leg pain and mobility limitation. 
Ex-drinker - previously consumed 1-1.5 litres cider daily for approximately 20 years, ceased after attending alcohol clinic. 
Significantly limited functional status with impaired activities of daily living due to mobility issues and leg pain.
Ex smoker - 20 pack/year history

On Examination:
Alert. Pale and tired. Not jaundiced.
Observations: Initial venous blood gas - Hb 61, pH 7.35, Lactate 1.3
• Cardiovascular: Heart sounds normal. No peripheral oedema. No palmar erythema. Scattered spider naevi on chest but no clear clinical evidence of chronic liver disease
• Respiratory: Chest clear to auscultation
• Abdomen: Soft, non-tender throughout. No organomegaly palpable
• Skin: Pale. Scattered spider naevi on chest. No jaundice
• Other: No asterixis

Investigations:
• Venous blood gas (26/02/26): Hb 61, pH 7.35, Lactate 1.3
• Further blood tests pending
• Chest X-ray requested

Impression:
Upper gastrointestinal bleed secondary to dual antiplatelet/anticoagulant therapy (Apixaban and Aspirin) following vascular surgery for limb ischaemia
Most likely peptic due to aspirin use - alcohol excess makes liver disease a possibility but no clinical evidence of portal hypertension.

Management Plan:
1. Urgent transfusion of 2 units packed red cells - blood available within 10 minutes
2. Large bore IV cannula
3. IV PPI stat followed by PPI infusion
4. Stop Apixaban temporarily. Continue Aspirin given vascular graft
5. Upper GI endoscopy when adequately resuscitated - aim for tomorrow. If haemodynamic compromise, consider earlier endoscopy
6. Chase pending blood tests including full blood count, clotting screen, renal function, liver function
7. Review chest X-ray when available
8. Allerton bed
9. TEP full escalation.

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Summary:

Investigations:

Tasks

Feedback

• Clinical assessment was thorough and appropriate for an acute upper GI bleed presentation
• Good recognition of the need for urgent resuscitation and blood transfusion with appropriate escalation to blood bank
• Excellent attention to medication history particularly regarding anticoagulation timing, which is crucial for procedural planning
• Social history taking was comprehensive and identified significant safeguarding concerns (housebound for 2 years, social isolation, lack of home adaptations)
• Consider earlier documentation of baseline observations (HR, BP, RR, temperature, SpO2) beyond the VBG results for completeness
• The examination was appropriate but could have included more detail on cardiovascular status given the history of vascular surgery and current blood loss (peripheral pulses, capillary refill time, JVP)
• Good recognition of spider naevi and consideration of chronic liver disease, though further questioning about stigmata of chronic liver disease could have been more systematic
• Escalation plan discussion was appropriately flagged but should be addressed earlier in the admission given severity of presentation
• The significant alcohol history (20 years of heavy drinking) warrants more detailed exploration of liver disease screening and consideration of whether patient may be at risk of alcohol withdrawal
• Safety-netting: No clear discussion documented about what signs should prompt patient to call for help (fresh blood, increased weakness, chest pain, etc.)
• Consider earlier involvement of social services given the profound social isolation and mobility limitations - this patient has been housebound for 2 years which represents a significant safeguarding concern