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Refined clerking (20 days ago 13:02)

Refined clerking Tue 17 March 2026 13:02

Last Modified: 20 days ago

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Medical ST5 Miller Clerking
Date: 26/03/2017 13:02

Presenting Complaint:
Abdominal pain and diarrhoea

History of Presenting Complaint:
Leslie is a 59-year-old lady presenting with colicky abdominal pain and chronic loose stools. The pain is intermittent, originating in the lower abdomen, radiating around to the back, and follows a colicky pattern. She has not eaten since Sunday as eating precipitates an urgent need to open her bowels. She has been vomiting watery fluid, which she attributes to having an empty stomach. She has not opened her bowels for several hours prior to this assessment.

She reports chronic diarrhoea occurring daily for several years, which is significantly impacting her quality of life. She is unable to leave the house partly due to urgency of bowels and partly due to postural dizziness. She has been unable to manage the stairs at home and has relocated to her dining room. She is not sleeping at night. She reports low mood and has expressed suicidal ideation in the context of her debilitating symptoms.

She also has a background of postural hypotension, causing dizziness and disorientation on standing, for which she uses a walking frame. This has confined her to the house for several years.

Past Medical History:
• Postural hypotension - on antihypertensive medication
• Low mood / suicidal ideation

Drug History:
• Antihypertensive agent (name not specified)

Recently Stopped Medications:
• Gabapentin - stopped by hospital team (date not specified)

Allergy History:

Social History:
Living situation. Lives in a house with her daughter.
Mobility. Uses a walking frame due to postural hypotension with dizziness and disorientation on standing. Has not been outside the house for several years. Unable to manage stairs; sleeping downstairs in the dining room.
Functional Status. Significantly limited activities of daily living. Housebound. Difficulty with washing.

On Examination:
General Appearance. Unwell, distressed, exhausted.
Observations: Not documented.
• Abdomen: Distended with audible/palpable gas. Tender on palpation.
• Cardiovascular: Not commented upon.
• Respiratory: Not commented upon.
• Neurological: Not examined.

Investigations:
• Abdominal X-ray: Challenging interpretation due to poor quality film. No evidence of stool in the rectum. Impression of thickened colonic wall on the left side. Evidence of faecal loading. Right-sided gas and faeces. Transverse colon not visualised. No evidence of obstruction.
• Chest X-ray: Small left basal pleural effusion. Lung fields otherwise clear. Possible bilateral hazy opacification, most likely atelectasis.

Impression:
Overflow constipation secondary to poor mobility, in the context of chronic loose stools and colicky abdominal pain.
Differential Diagnoses: Left-sided colonic pathology given impression of thickened colonic wall on abdominal X-ray; cross-sectional imaging may be required if symptoms persist.
Secondary issues: Low mood with expressed suicidal ideation. Postural hypotension with significant functional impairment.

Management Plan:
1. IV fluids for rehydration.
2. Trial of laxatives for overflow constipation.
3. Urgent psychiatry review given low mood and expressed suicidal ideation.
4. Bloods including FBC, U&E, CRP, LFTs and coagulation (note: not on anticoagulants).
5. If symptoms fail to resolve with initial management, consider cross-sectional imaging (CT abdomen and pelvis) to further evaluate thickened colonic wall.
6. Ongoing monitoring of observations, fluid balance, and bowel output.

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Refined clerking Tue 17 March 2026 13:02

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