Physician's Assistant

Patient Details

Refined clerking (239 days ago 22:27)

Refined clerking Sun 10 August 2025 22:27

Last Modified: 239 days ago

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Medical ST4 Miller Clerking

Presenting Complaint:
Abdominal pain and jaundice for 4 days

History of Presenting Complaint:
Epigastric / sternal pain that began on Tuesday night, described as one of the worst nights he had experienced. Initially took over-the-counter co-codamol (paracetamol 500mg and codeine 30mg) but consumed 20 tablets in 3 days, supplemented with additional paracetamol.

Developed dark brown urine and progressive jaundice from Thursday onwards, associated with significant lethargy. Pain has now migrated from sternum to right upper quadrant. Scheduled OGD with duodenal biopsy was cancelled due to elevated INR. No fever reported.

Eating causes abdominal discomfort and bloating. Poor PO intake as a result.

Past Medical History:
• Autoimmune hepatitis with established cirrhosis and portal hypertension, pANCA positive
• Diffuse cholangiopathy on imaging  
• Portal vein thrombosis (March 2024) - on warfarin, radiologically stable
• Iron deficiency anaemia secondary to haemorrhoids and portal hypertensive gastropathy
• Previous hepatic decompensation with ascites (March 2023)
• Focal liver abnormality LIRADS 3 - under surveillance
• Recent sudden onset sensorineural hearing loss and vertigo (right-sided)
• Listed for liver transplantation since August 2023 - currently suspended due to porta hepatis adenopathy
• Osteopenia

Drug History:
• Advagraf 3mg PO OD
• Prednisolone 7.5mg PO OD  
• Furosemide 40mg PO OD
• Ursodeoxycholic acid 500mg PO BD
• Carvedilol 6.25mg PO BD
• Omeprazole 20mg PO OD
• Warfarin as per anticoagulant clinic
• Adcal-D3 BD

Allergy History:
NKDA

Social History:
Lives with wife and 4-year-old daughter Emily. 
No alcohol or smoking

On Examination:
General Appearance: Alert, orientated, jaundiced, appears unwell
Observations: Resp Rate	18 /min O2 Sats	96 % Air BP 147/92 mmHg Pulse 72 /min T 36.6 °C
• No asterixis, GCS 15
• Icteric sclerae, pale, sweaty
• Dry mucous membranes
• Abdomen: Soft with mild right upper quadrant tenderness
• Cardiovascular: Heart sounds normal
• Respiratory: Chest clear

Investigations:
• CRP 73 (raised)
• Paracetamol level 8
• Sodium 124 (previously 137)
• Urea 10.4 (previously 4.3)
• Creatinine 96 (baseline 60)
• Albumin 20 (previously 21)
• Bilirubin 232 (previously 64)
• ALT 68 (previously 58)
• ALP 187 (previously 181)
• INR 3.3 (previously 1.5)
• White cells 8.2, neutrophils 6.9
• Platelets 82 (previously 70)
• Hb 134 (previously 118)
• CT Abdomen/Pelvis (07/03/25): Liver cirrhosis, portal hypertension, intrahepatic bile duct strictures, 1.2cm hypervascular lesion segment 2 (unchanged), new pathological porta hepatis adenopathy (largest node 2cm), significant progression of perihilar soft tissue mass
• CT AP with contrast (not triple phase): No new thrombus, mass or acute cholecystitis. Stable IHD dilatation.
• Bedside USS: Distended gallbladder with single stone, CBD 13.3mm with possible intraductal stone
• Chest X-ray: Clear lung fields

Impression:
Possible acute cholangitis secondary to choledocholithiasis leading to decompensation in AIH-related cirrhosis
- Jaundice
- No evidence of GIB, HE, Ascites
Potential for biliary obstruction secondary to porta hepatis lymph node also considered
Accidental paracetamol overdose
Acute kidney injury 1 with hyponatraemia
- Most likely dehydration-related but potential for adrenal insufficiency in light of long-term steroid use

Plan:
1. IV antibiotics for cholangitis [/]
2. IV fluids and IV Mg [/]
3. N-acetylcysteine infusion for paracetamol overdose - continue until hepatology review [/]
4. Suspend warfarin and bridge with LMWH to facilitate potential ERCP [/]
5. Analgesia [/]
6. Bloods (FBC, UE, LFT, INR) after 2nd bag of NAC
7. Septic screen including blood cultures, MSU [/]
8. Chest X-ray [x]
9. Input/output monitoring
10. Hepatology ward bed - level 1 - can go before PTWR
11. Add GGT [/]
12. MRCP [/]
13. Full escalation of care 
14. Double dose of steroids while admitted [x]
15. Suspend carvedilol, furosemide, PPI in AKI [x]
16. Tac level mane [/]
17. Discussed with Hepatology Consultant Dr Rhodes
- Add haemolysis screen [/]
- Add immunoglobulins [/]
- Add viral hepatitis screening [/]
- Continue current dose of tacrolimus
- Don't give gent, taz instead.
- Pull to SWLU [_]
18. Hepatology SeeEHR [x]

Overnight plan:
- Bloods now: Viral screen, septic screen, GGT, haemolysis screen
- Bloods at 08:00 after NAC: FBC, UE, LFT, INR, VBG, Tacrolimus levels (before tac dose given)

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Refined clerking Sun 10 August 2025 22:27

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