Physician's Assistant

Patient Details

Refined clerking (127 days ago 14:29)

Refined clerking Sun 30 November 2025 14:29

Last Modified: 127 days ago

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Medical ST5 Miller Clerking

Presenting Complaint:
Post-oesophageal stent pain and reduced oral intake

History of Presenting Complaint:
This 91-year-old gentleman underwent oesophageal stenting on 27th November 2025 (3 days ago) for T3N2M0 oesophageal adenocarcinoma. The procedure was technically challenging due to an impassable stricture at 20cm, requiring neonatal endoscope and wire-guided stent deployment. Post-procedure, he developed intermittent lower neck pain described as waves of discomfort, particularly triggered by talking. This is associated with persistent nausea and significantly reduced oral intake. Since the procedure, he has managed only a couple of spoonfuls of soup and scrambled egg, with immediate nausea following ingestion. He reports feeling a persistent lump sensation in his throat. His daughter is concerned about dehydration as his fluid intake has been minimal. Pain initially managed with paracetamol was ineffective, morphine provided some relief but caused additional drowsiness. Anti-emetics given today have provided some improvement in nausea symptoms.

Past Medical History:
• Oesophageal adenocarcinoma T3N2M0 - diagnosed July 2025, MDT decision for best supportive care
• Palliative radiotherapy 20Gy in 5 fractions completed September 2025
• CKD stage 3
• B-cell non-Hodgkin's lymphoma left eye - treated 2013
• Hypertension
• Myocardial infarction 1994
• Total hip replacement right 2012

Drug History:
• Aspirin 75mg PO OD
• Bendroflumethiazide 2.5mg PO mane
• Omeprazole 20mg PO OD
• Atenolol 25mg PO OD

Allergy History:
• NKDA

Social History:
Lives at home with wife. Independent mobility prior to recent deterioration. Previous occupation as panel beater. Ex-serviceman. Non-smoker, non-drinker. Daughter provides support but does not live with patient. Weight loss of 1.5 stones since September 2025.

On Examination:
General Appearance: Alert, appears dehydrated, weight loss evident
Observations: Not fully documented
• Cardiovascular: Heart sounds normal, no peripheral oedema noted
• Respiratory: Clear chest on auscultation
• Abdomen: Soft, tip of stent not palpable abdominally (appropriate position)
• Other: Clinical signs of dehydration present (skin turgor, dry mouth)

Investigations:
• Albumin: 34
• Creatinine: 109 (baseline)
• CRP: 63
• Urea: 10.4
• Platelets: 145 (chronically low)
• Lymphopenia noted, otherwise normal FBC
• Upper GI Endoscopy (July 2025): Benign oesophageal narrowing at 20cm, oesophageal malignancy at 30cm
• CT Chest/Abdomen/Pelvis (July 2025): T3N2M0 oesophagetal cancer, pulmonary fibrosis, radiopaque gallstones, aneurismal abdominal aorta 3.7cm, left groin hernia
• Oesophageal stenting (27/11/2025): Wire-guided deployment, radiologically confirmed good position

Impression:
Pain and nausea likely secondary to oesophageal stent
- To ensure has not slipped
Clinical but not biochemical dehydration secondary to poor oral intake

Management Plan:
1. IV fluid resuscitation for dehydration
2. Chest and abdominal X-ray to confirm stent position and rule out slippage
3. Anti-emetics and analgesia to manage post-stent symptoms
4. IV omeprazole to manage potential reflux post stent
5. Encourage liquid diet and fluids as tolerated, dietitian review if prolonged admission
6. Resume regular medications when oral intake improves
7. Gastroenterology ward admission for symptomatic management but aiming home today if symptoms improved with treatment
8. TEP DNAR form completed - patient not suitable for CPR given advanced malignancy and frailty

Patient counselled that symptoms are expected following stent insertion and should improve over 72 hours as oesophagus accommodates to stent. Aim for same-day discharge if symptoms improve and oral intake adequate.

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Refined clerking Sun 30 November 2025 14:29

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