Physician's Assistant

Patient Details

Refined clerking (198 days ago 22:17)

Refined clerking Sat 20 September 2025 22:17

Last Modified: 198 days ago

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Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Jaundice and feeling generally unwell

History of Presenting Complaint:
This 73-year-old lady presents with a 2-week history of feeling generally unwell. She reports pale coloured stools and generalised itching but denies dark urine or abdominal pain. She has been managing well at home in Darlington, walking up hills without breathlessness and remaining active with gardening. She lives independently and cares for her grandchildren. No associated nausea, vomiting, or significant weight loss noted. Recent blood tests revealed rising bilirubin levels (from 67 to 94 over 2 days) prompting urgent CT imaging.

Past Medical History:
• Left breast DCIS treated with wide local excision - mammogram surveillance with no evidence of recurrence, follow-up stopped January 2024
• Hypothyroidism - stable on thyroxine
• Hip arthritis

Drug History:
• Thyroxine (dose not specified)

Allergy History:
Not documented

Social History:
Lives independently in Darlington. Very active lifestyle including hill walking and gardening. Previous occupation as scientist at ICI Mortel. Cares for grandchildren. Mobility excellent - can walk briskly up hills without breathlessness. No formal care requirements.

On Examination:
General Appearance: Alert, well-appearing but jaundiced
Observations: Not fully documented
• Abdomen: Palpable solid mass felt in epigastric region described as 'pushing on something'
• Other systems: Not fully examined

Investigations:
• Bilirubin: 94 (increased from 67 two days prior)
• ALP: 606
• ALT: 509 (normal)
• CRP: 4
• Urea: 4.3
• FBC: Microcytosis and lymphocytosis without anaemia
• ECG: Sinus rhythm with first degree AV block, PR interval 214ms, no evidence of ischaemia
• CT Thorax/Abdomen/Pelvis: 24mm hypodense mass in head of pancreas with associated distal pancreatic duct dilatation and parenchymal atrophy. Marked CBD and intrahepatic duct dilatation. Mass does not involve adjacent organs or major vessels. No gallstones. Simple hepatic and renal cysts. No peritoneal deposits or ascites. Slightly prominent left para-aortic lymph nodes. No skeletal metastases. Staging T2N0Mx (indeterminate para-aortic lymph nodes)

Impression:
Pancreatic head mass with biliary obstruction - likely pancreatic adenocarcinoma
Differential Diagnoses: Rare pancreatic conditions that mimic malignancy
Obstructive jaundice secondary to pancreatic head mass

Management Plan:
1. Urgent ERCP for biliary decompression and tissue sampling
2. Blood tests: IgG4 levels and CA19-9 tumour markers
3. PET-CT to assess para-aortic lymph node involvement
4. Upper GI MDT referral for surgical evaluation
5. Upper GI CNS referral for patient support
6. Commence pancreatic enzyme replacement therapy for malabsorption
7. Nutritional supplements to prevent further weight loss
8. Gastroenterology ward admission for urgent workup
9. Full escalation plan to be discussed including fitness for major surgery (Whipple procedure)

Recheck bilirubin and inflammatory markers tomorrow morning. Consultant gastroenterologist review in morning to coordinate care plan.

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Refined clinic letter (198 days ago 22:03)

Refined clinic letter Sat 20 September 2025 22:03

Last Modified: 198 days ago

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Diagnosis:
Radiological head of pancreas cancer with obstructive jaundice
- Radiological staging T2 N0 Mx

Other Medical Diagnoses:
• Left breast DCIS - treated with wide local excision, mammogram surveillance until January 2024, no recurrence
• Hypothyroidism - on thyroxine therapy
• Hip arthritis

Current Medications:
• Thyroxine XX mcg PO OD
• Pancreatic enzyme replacement therapy - STARTED TODAY
• Ensure compact protein - STARTED TODAY
• Omeprazole 20mg PO OD

Investigations:
• CT Thorax, Abdomen and Pelvis (September 2025): 24mm hypodense mass in head of pancreas with distal pancreatic duct dilatation and parenchymal atrophy. Marked CBD and intrahepatic duct dilatation. Slightly prominent left para-aortic lymph nodes. No metastases or peritoneal deposits. Staging T2 N0 Mx (indeterminate para-aortic lymph nodes)
• Bilirubin: 94 (increased from 67 two days prior)
• ALP: 606 (elevated)
• ALT: 50
• Urea: 4.3
• CRP: 4
• FBC: Microcytosis and lymphocytosis without anaemia
• ECG: Sinus rhythm with first degree AV block, PR 214ms, no ischaemia
• Vital signs (20/09/2025 20:35): BP 185/108, HR 68, RR 18, Temp 37°C, Sats 96%, EWS 0

Management Plan:
1. IgG4 levels
2. CA 19-9 tumour marker
3. Upper GI MDT referral
4. Upper GI CNS referral
5. ERCP for biliary decompression and tissue sampling
6. Consideration of PET-CT scan to assess para-aortic lymph node involvement
7. Pancreatic enzyme replacement therapy, PPI and nutritional supplementation

I had the pleasure of meeting Mrs Lowry on the Acute Medical Unit this evening.

I was sorry to hear about the symptoms she has been experiencing for the past 3 weeks with weight loss of 7lbs, pale floating stools, nausea with 2 episodes of vomiting, epigastric fullness and early satiety.

She attended her GP yesterday for these symptoms and jaundice was noted. She felt more unwell and presented to A&E.

This evening she has also developed some mild pruritis.

She is very active, living independently in Totnes with her cousin. She has an essentially unlimited exercise tolerance, does Tai Chi, gardens and cares for her grandchildren.

On examination, she appeared thin with icteric sclera. Abdominal examination revealed a palpable epigastric mass. Other examination was unremarkable.

She was keen to discuss the results of her investigations, I did offer to come back in the morning with one of the nurses and offered her family to be present. However, she is very pragmatic and wished to know the result now. I explained that, unfortunately, her CT scan demonstrates a 24mm hypodense mass in the head of the pancreas with associated biliary obstruction and slightly prominent para-aortic lymph nodes. Blood tests confirm obstructive jaundice with rising bilirubin (now 94, up from 67) and elevated alkaline phosphatase at 606.

I have discussed the diagnosis of possible pancreatic cancer, explaining the need for biliary decompression  and tissue sampling with ERCP. We briefly discussed that the presence of lymph nodes needs further clarification, likely with PET-CT but that we would discuss this with the team at our Upper GI MDT.

She has been started on pancreatic enzyme replacement therapy, PPI and nutritional supplements. She remains in hospital but could have these investigations undertaken on an urgent outpatient basis.

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