Physician's Assistant

Patient Details

Refined clerking (281 days ago 11:31)

Refined clerking Sun 29 June 2025 11:31

Last Modified: 281 days ago

MRN:

Content:

Medical ST4 Miller Clerking

Presenting Complaint:
Upper abdominal pain and vomiting for 8 months

History of Presenting Complaint:
This 37-year-old military serviceman presents with an 8-month history of progressive upper abdominal pain and vomiting. Initially developed gastro-oesophageal reflux symptoms 6 years ago, well controlled on lansoprazole. In November 2024, developed new onset vomiting, initially nocturnal but now constant throughout the day (30+ episodes daily). Associated with severe upper abdominal pain described as a constant dull ache that waxes and wanes in intensity. Pain temporarily relieved by vomiting or defecation. Reports 10kg weight loss over recent months. Vomiting episodes contain food and occasionally appear blood-tinged (patient has photographs). Experiences alternating constipation and diarrhoea, with episodes of rock-hard stool requiring significant straining. Severe functional impairment - unable to leave house due to frequency of vomiting. Sleep severely disrupted. Recently returned from 4-month military deployment to Middle East where symptoms were present but managed. Attended Surgical Assessment Unit on 27/06/2025, diagnosed with gastritis and prescribed ondansetron and co-codamol with limited benefit.

Past Medical History:
• Gastro-oesophageal reflux disease (2018) - well controlled on lansoprazole
• Non-specific Back pain (2023) - treated with codeine for approximately 1 year
• HSV (2018)

Drug History:
• Lansoprazole 15mg PO BD (6 years)
• Aciclovir 400mg BD
• Gaviscon PRN
• Ondansetron 4mg PO TDS (started 27/06/2025)
• Co-codamol 30/500mg PO QDS PRN (started 27/06/2025)

Allergy History:
• Duloxetine -> Anxiety

Social History:
• Recent travel to Middle East (military deployment)
Lives with partner and family. Military serviceman. Recently returned from 4-month deployment to Middle East. Non-smoker, vapes occasionally. Wife works in plastic surgery department. 
Alcohol consumption: approximately 4-5 cans of beer nightly, occasional spirits (bottle of rum consumed over couple of days).

On Examination:
General Appearance: Dry MMs
• Abdomen: Tiny umbilical hernia, no scars, epigastric tenderness
• Cardiovascular: Normal HS
• Respiratory: Clear chest on auscultation

Investigations:
• OGD (December 2024): Poorly tolerated, normal appearance of oesophagus, stomach and duodenum
• CT Abdomen and Pelvis (December 2024): Mild premature diverticulosis affecting descending and proximal sigmoid without acute features, mesenteric fatty deposition, small uncomplicated umbilical hernia, no cause for symptoms identified
• Bloods (27/06/2025): CRP <1, Creatinine 62, Urea 1.4, Total protein 88, Albumin 54, ALT 74 (previously 42), Lipase 33, FBC normal
• TTG (November 2024): Negative

Impression:
Multifactorial symptoms with
1. Functional gut symptoms with IBS-C
2. Functional dyspepsia
3. Alcohol-related gastritis
most likely contributing
- But weight loss and severity of symptoms is concerning and warrants further investigations
Possible UGIB - most likely Mallory-Weiss tear 
Elevated ALT requiring investigation
Clinical dehydration
Alcohol misuse

Management Plan:
1. IV fluids and antiemetics for dehydration and symptom control
2. Bloods including non-invasive liver screen, TTG, HbA1c, thyroid function, vitamin D, group and save
3. Upper GI endoscopy with small intestinal biopsy to assess for upper GI bleeding and exclude other pathology - IPT / urgent OPT depending upon GBS
4. Consider empirical H. pylori eradication therapy for 2 weeks if able to manage vomiting today
5. IV PPI therapy and regular laxatives
6. Ultrasound liver - if LFTs still deranged then as IPT
7. if admitted: IV Vitamins, CIWA, Alcohol nurse review, Dietetic review
8. IVI
9. Gastroenterology bed most likely

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Refined clerking (281 days ago 11:15)

Refined clerking Sun 29 June 2025 11:15

Last Modified: 281 days ago

MRN:

Content:

Medical ST4 Miller Clerking

Presenting Complaint:
Upper abdominal pain and vomiting for 8 months

History of Presenting Complaint:
This 37-year-old gentleman presents with an 8-month history of progressive upper abdominal pain and vomiting. The pain is described as a constant dull ache in the upper abdomen that fluctuates in intensity but never completely resolves. The pain is associated with significant bloating and abdominal distension.

Vomiting began in November 2024, initially occurring at night when lying down. This has progressively worsened and now occurs up to 30 times daily, preventing him from leaving the house. The vomitus contains recognisable food particles and he has noted some blood-stained vomit in recent days, described as pinky-red in colour. He has lost approximately 10kg in weight.

Bowel habit is erratic, alternating between severe constipation (requiring straining, rock-hard stools causing pain) and loose stools, sometimes within the same day. He reports feeling constantly dehydrated despite fluid intake and has not had a full night's sleep due to symptoms. Opening bowels provides temporary relief of abdominal pain.

He has a background of acid reflux treated with lansoprazole for 6 years, which had been well controlled until recent symptom onset. He was recently deployed with the military to the Middle East but symptoms preceded deployment. He attended the Surgical Assessment Unit on 27/06/2025 and was discharged with a diagnosis of gastritis.

Past Medical History:
• Gastro-oesophageal reflux disease (6 years)
• Back pain (previous year - treated with codeine)

Drug History:
• Lansoprazole 30mg PO BD (6 years)
• Co-codamol 30/500mg PO PRN (from 27/06/2025)
• Cyclizine PO PRN (from 27/06/2025)

Allergy History:
NKDA

Social History:
Serving military personnel - recently deployed to Middle East for 4 months
Lives with partner and family
Smoking: Vapes
Alcohol: 4-5 cans of beer nightly, occasional spirits (couple of days to finish a bottle of rum)
Functional Status: Severely impaired - unable to leave house due to frequent vomiting

On Examination:
General Appearance: Unwell, appears dehydrated, abdominal distension noted
Observations: Not documented
• Abdomen: Visibly distended, tender on palpation
• Other systems: Brief examination performed - no specific abnormalities documented

Investigations:
• OGD (December 2024): Poorly tolerated, normal appearance of oesophagus, stomach and duodenum
• CT Abdomen/Pelvis (December 2024): Mild premature diverticulosis affecting descending and proximal sigmoid without acute features, mesenteric fatty deposition, small uncomplicated umbilical hernia, no cause for symptoms identified
• Bloods (27/06/2025): CRP <1, Creatinine 62, Urea 1.4, Total protein 88, Albumin 54, ALT 74 (previously 42), Lipase 33, FBC normal
• TTG (November 2024): Negative

Impression:
Functional dyspepsia with severe constipation
Differential Diagnoses: H. pylori gastritis, gastroparesis, alcohol-related gastritis
Secondary issues: Alcohol excess, dehydration, weight loss

Management Plan:
1. IV fluids and anti-emetics via cannula to control vomiting
2. Urgent repeat FBC and U&Es to exclude anaemia from GI bleeding
3. Urgent upper GI endoscopy (2-week wait) - if Hb dropped: inpatient scope; if stable: outpatient Monday/Tuesday
4. H. pylori eradication therapy (empirical treatment given poor OGD tolerance)
5. Regular laxatives to improve bowel function
6. Alcohol cessation advice and support
7. Gastroenterology outpatient follow-up in 2 weeks
8. Medical ward admission if vomiting cannot be controlled in A&E
9. Escalation plan: Suitable for full escalation including ITU if required

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Summary:

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