Physician's Assistant

Patient Details

Refined clerking (9 days ago 12:02)

Refined clerking Sat 28 March 2026 12:02

Last Modified: 9 days ago

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Content:

Presenting Complaint:
Epigastric pain

History of Presenting Complaint:
62-year-old lady has had constant epigastric pain since January, with intermittent flares. The pain does not radiate and is not affected by eating, drinking, posture or movement, although she feels more uncomfortable when mobilising. She has had mild nausea but no vomiting, diarrhoea or change in bowel habit.

She has previously been tried on antacid treatment including famotidine and esomeprazole without benefit. She was referred to gastroenterology via a choose and book referral on 4 March but has not yet heard back. She presented with a marked worsening of the pain yesterday while at work and has required inpatient analgesia, which has not made a significant difference.

She has been on Mounjaro for around 18 months and is currently on 7.5 mg. She has lost weight gradually over that period, from 90 kg to around 82 kg, with no rapid recent loss. There is concern about possible biliary pathology or Mounjaro-related upper gastrointestinal side effects.

Past Medical History:
• Type 2 diabetes mellitus, latest HbA1c: 60 mmol/mol
• Hypertension
• Previous breast cancer, treated with lumpectomy and reduction surgery
• Osteoporosis

Drug History:
• Anastrozole 1mg PO OD
• Pregabalin 25mg PO BD
• Metformin MR 1g PO BD
• Atorvastatin PO
• Ramipril 2.5mg PO OD
• Calci-D3 PO OD
• Alendronic acid 70mg PO weekly
• Mounjaro 7.5mg SC weekly

Allergy History:
• Penicillin - allergy

Social History:
Lives in Holsworthy, North Devon. Previously lived in York but moved back after her mother's death. She works and remains independent. No alcohol history or smoking history was provided.

On Examination:
Alert and comfortable at rest.
Observations: T 36.6°C, HR 87, RR 18, BP 110/72, SpO2 95% on air
• Abdomen: Epigastric tenderness on palpation. No guarding reported. No radiation of pain.
• Cardiovascular: No abnormal findings reported.
• Respiratory: No abnormal findings reported.
• Neurological: No focal abnormality reported.
• Other: Mild jaundice noted clinically. Bedside ultrasound showed a fatty liver, with no clear biliary dilatation or obvious ductal obstruction seen.

Investigations:
• Bilirubin: 22
• ALT: 22
• ALP: 39
• Amylase: normal
• CRP: 4
• Urea: 11.1
• AST: normal
• WCC: 12.9
• Neutrophils: 11.61
• HbA1c: 60 mmol/mol

Impression:
Constant epigastric pain with mild hyperbilirubinaemia and normal liver enzymes. Differential diagnoses include Mounjaro-related upper GI side effects, biliary microlithiasis/retained stone, and other upper gastrointestinal pathology. Osteoporosis.

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Patient Details

Refined clerking Sat 28 March 2026 12:02

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