Physician's Assistant

Patient Details

Refined clerking (298 days ago 19:02)

Refined clerking Thu 12 June 2025 19:02

Last Modified: 298 days ago

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Medical ST4 Miller Clerking

Presenting Complaint:
Vomiting

History of Presenting Complaint:
Patient presented with acute onset nausea and vomiting starting this morning. Initially complained of vomiting with associated abdominal pain developing after episodes of being sick. Reports "bringing up blood" mixed with vomit, described as brownish rather than fresh red blood. Denies initial abdominal pain preceding vomiting. Continues to have ongoing nausea with dry retching and minimal production. Patient appears dehydrated and reports feeling unwell with reduced energy. Has history of significant alcohol use disorder with recent admission in April 2025 for alcohol withdrawal management when consuming 260 units per week.

Past Medical History:
• Alcohol use disorder - 260 units/week (April 2025)
• Restless leg syndrome
• Hypothyroidism
• Gastric ulcer (2004)
• Left hip osteoarthritis
• Depression
• Hypertension

Drug History:
• Thiamine 100mg PO OD
• Levothyroxine 100mcg PO OD
• Ropinirole 250-500mcg PO PRN nocte
• Citalopram 40mg PO OD

Allergy History:
• Penicillin - itching and lip swelling
• Co-amoxiclav - itching and lip swelling

Social History:
Lives alone in flat with daily carer support for cleaning and household tasks. Neighbour assists with shopping and washing. Limited mobility due to hip arthritis, uses walking aids. Previously lived in Crystal Palace, London before moving for rehabilitation. Ex-smoker of 55+ years, approximately 1 pack per week currently. Current alcohol intake: continues drinking vodka mixed with lemonade in 1:1 ratio, approximately 2 litres daily. Neighbour purchases alcohol weekly. Recognises addictive personality traits.

On Examination:
General Appearance: Alert but appears unwell, slightly agitated and anxious, showing signs of alcohol withdrawal with tremor
Observations: Not fully documented
• Abdomen: Epigastric tenderness, no obvious masses
• Cardiovascular: Not fully examined
• Respiratory: Chest examination planned
• Neurological: Mild tremor consistent with alcohol withdrawal
• Other: No peripheral oedema, no rashes, no leg tenderness. Tongue not excessively dry.

Investigations:
• Creatinine 44 (baseline 35)
• ALP 141
• INR 1.0
• Bilirubin 10
• Neutrophils 8.6
• MCV 110
• ANA positive
• Hepatitis B negative
• Hepatitis C negative
• HIV negative
• Venous blood gas: pH 7.13, lactate 11.1
• Repeat venous gas (1 hour later): pH 7.15, lactate 11.0
• Ultrasound liver (April 2025): Diffusely hyperechoic liver consistent with hepatic steatosis, no focal lesions, normal portal flow, no ascites

Impression:
Lactic acidosis secondary to alcohol use disorder
Coffee ground vomiting - ?upper GI bleeding vs metabolic
Alcohol withdrawal syndrome
No evidence of chronic liver disease on recent imaging

Management Plan:
1. Admit to Hepatology Ward
2. Serial blood gas measurements until pH normalised
3. IV vitamins and continue for 5 days
4. IV fluid resuscitation for dehydration
5. Encourage oral intake following vitamin replacement
6. Alcohol withdrawal management with CIWA
7. Abdominal ultrasound [/]
8. Add lipase, GGT, AST to blood tests [/]
9. Low threshold for cross-sectional imaging if develops abdominal pain
10. Chest X-ray [/]
11. Consider endoscopy if ongoing evidence of upper GI bleeding

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Refined clerking Thu 12 June 2025 19:02

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