Physician's Assistant

Patient Details

Refined clerking (35 weeks ago 05:24)

Refined clerking Mon 04 August 2025 05:24

Last Modified: 35 weeks ago

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Content:

Medical ST4 Miller Clerking

Presenting Complaint:
Recurrent vomiting episodes for several months in 2025

History of Presenting Complaint:
The patient presents with stereotypical episodes of severe nausea and vomiting that have been occurring throughout 2025. Each episode involves prolonged vomiting where she remains at the toilet bowl, vomiting continuously with only brief intervals of a few minutes between episodes. During these brief respites, she may manage to make a cup of tea but cannot tolerate any food or fluids during the episodes. The vomiting is associated with abdominal pain that occurs after vomiting, and headaches. She describes feeling weak and disoriented during episodes. These are new symptoms for her - she had never experienced similar episodes prior to 2025. No clear precipitating factors have been identified. The patient is currently caring for a 14-year-old child as a single mother, which she finds stressful.

Past Medical History:
• Mixed anxiety and depressive disorder (2020)
• Bipolar disorder (2021)
• Supraventricular tachycardia

Drug History:
• Lamotrigine 100mg PO BD
• Medroxyprogesterone depot injection 150mg IM every 12 weeks
• Bisoprolol 2.5mg PO BD

Allergy History:
Not documented

Social History:
Single mother caring for a 14, 12 and 7 year-old children at home. Finds this stressful. HCA in MAU.  Uses e-cigarettes (normal vaping). Denies recreational drug use.

On Examination:
General Appearance: Alert, appeared to feel nauseated during consultation
Observations: HR 94/min, BP 124/91 mmHg, Temp 37.4°C, RR 14/min, O2 sats 98% on air
• Abdomen: SNT
HS normal
Chest clear

Investigations:
• OGD June 2025: Normal
• CRP: <1
• ALP: 134 (elevated)
• White cells: 14.6 with neutrophils 12.7
• pH: 7.42 with lactate 5.8, subsequently 7.49 with lactate 6.2
• NEWS score: 1

Impression:
Recurrent vomiting episodes - Likely cyclical vomiting syndrome
Exclude:
- Gallbladder pathology
- Coeliac disease
Elevated ALP and neutrophilia may be secondary to recurrent vomiting

Management Plan:
1. Symptomatic management during acute episodes
2. Abdominal ultrasound scan to assess gallbladder
3. Coeliac screen (tissue transglutaminase antibodies)
4. Consider trial of antiemetic therapy
5. Follow-up in clinic to review investigation results
6. Patient education regarding cyclical vomiting syndrome
7. Gastroenterology outpatient referral if symptoms persist
8. Conservative management appropriate - not requiring admission

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Refined clerking Mon 04 August 2025 05:24

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