Judy williams 344813 59 year old lady medications list laxita 1 to 2 as required morphine sulfate 10 mg per 5 mil oral solution 5 to 10 ml up to 4 times a day open brackets 10 to 20 mg 4 times a day as required creon 25000 capsules as required 3 times a day isomeprazole 20 mg once a day ibuprofen 400 mg 3 times a day metoclopramide 10 mg 3 times a day paracetamol 500 mg as required well a gram up to 4 times a day as required symbicort 200 / 6 turbuhaler inhale 1 dose twice per day evo rel 50 patches every 3 to 4 days vagirox vaginal tablets 1 twice weekly testosterone transdermal gel 1 eighth of a sachet daily and spread over a large area of skin and progesterone micronized 100 take 2 per day while using transdermal estradiol past medical history asthma celiac disease 2012 osteopenia 2017 oh god I know this woman locally advanced pancreatic cancer t 4 n 1 with resultant biliary obstruction on ct most recent imaging ct pancreas 12/21/2025 highly concerning for a rapidly progressing pancreatic malignancy with a poorly enhancing mass in the uncinate process of the pancreas measuring approximately 23 millimeters in diameter soft tissue abutting the sma on its right side normal diameter the smv is narrowed in its superior portion immediately adjacent to the confluence of the splenic vein ercp to achieve biliary drainage undertaken on the december 29 6 cm metal stent placed with signs of bile contrast drainage following had post procedural diclofenac as well as fluid following to decrease risk of pancreatitis investigations ast hemolyzed creatinine 35 normal potassium and sodium liver function test bilirubin 42 from previous peak of 81 alt 61 improving also and alp a 187 also improving amylase 39 crp 73 urea 3.6 full blood count white cells 13 neutrophils 11.17 hemoglobin a 124 sodium a 128 and calcium 1.1 ionized on the venous blood gas with ph 7.39 ph so crp was is 73 today but was 4 on the december 17 sorry I've been trying to pee all night okay I'm really sorry I've been running around and called up to the ward can't say anything I've just been so sorry okay happy to hear that the nurses have put you up on a pca and you're feeling more comfortable more comfortable so pain that's brought you in by now do you mind telling longer so the story my first bit of pain well upper quadrant the only reason I was to the upper quadrant is because I had that was 1 last 1 I've told you a story for itt okay okay so you're up to speed so the ercp day yeah yeah a couple of days of worst pain for a while I've expected pain on I don't opioid naive I've never had I've couple of zomor zomor yeah I started milligrams twice daily on monday upped it within a day to 20 which is where I've been yeah yesterday I was like this is a really good day slept really well mhmm I didn't have enough cells so I've gotta have an eu pressure eus and biopsy yeah choose not more pain initially I thought oh it's in my head because I'm going through a procedure mhmm but it was not no no and it's escalated through the day mhmm bit early mhmm was looking at the stents but it's really not much better exactly but it was 127 arthritis that and now I'm I don't know what it was was yeah yeah that was a that's true stent it's true yes it so it certainly seems the stent's working well yeah and I I haven't got loose potty poo anymore I'm on that's good cool or felt like it was going the right way yesterday never experienced even I've taken childbirth over this so sweet got a bit hot okay I feel a bit hot now my temperature was 37 1 or 37 it is is and I've got like thermally things on you've gotta help some podcasts yeah it really did oh well the day I just didn't really feel like eating mhmm gonna have a bit of breakfast bit of soup at lunch nothing else cold no no I ask because you're copd bit pleuritic mhmm yeah it has been because it's where it's sitting of course yeah it's I mean you're up to 73 was all before and your white cells have come up to 50 it kind of fits with the possibility of infection yeah it could be biliary infection ghrelaryngitis oh because that can be a complication of that biliary instrumentation when you had it in your ercp I wouldn't expect it to come on at this stage to be honest I'd expect it to develop meningitis sooner late isn't it there's a possibility that you had a small aspiration pain very sorry no pain is very specific well you've got a sphincter and ampulla there to try and stop bacteria getting into your biliary tree there's the chance that bacteria can translocate up it's not that specific I think it's the academic really only difference between the use of the metronidazole to treat might have been 127 and then 30 and now it's gone up to 40 something which can be helpful I don't think it's blocked think you'd expect that your bilirubin will be just as high as it will oh yeah and you usually block this fast stable sludge on your imaging sludge they'd never swell out stones if I'm not sure I'm just going to answer quickly questions on about your tests or anything I can answer after just say you know some things some other tests please are you all medical experts no a gp are you are you tested now yeah yeah yeah yeah yeah your pain isn't it I just have a look at your hands and just take it is that okay feel to sit me it's alright if not I can just listen your arms sorry sorry I'm sorry I'm sorry sorry I'm I'm sorry I'm painful it's I think it's gonna change your mood to be honest with you yeah yeah you'll get a chest x-ray and make you a chest x-ray see where you've got an infection we'll an ultrasound of your abdomen and then look at the thing you retrieve it and then get a stent I think that'll be patent and have a look quite tender mhmm quite hard really but I haven't opened my bowels today I did yesterday but it's getting hotter mhmm yeah you were able to eat and drink but you're not vomiting not vomiting I have felt like food since I asleep at lunch yeah I've got a bit of nausea so I think it's a mhmm but ling here a little bit of reflux mhmm mhmm if the potential is a fibroid reflux disease then it's a bit less likely to present it presents to you as well when we do your chest x-ray we see it's it's the normal and that's case and you do need to have a sense of it yes yeah they go they don't really go into the protein not just gonna sit up and be yeah and they're run by themselves so we we can have it's hard it's weirdly my urine output pretty odd can't quite work that out so my whole body wants that mhmm so that work I can't work that way no I can't work that way either urine is yeah I'm sorry yeah the toe is also the right nose and crepitations and this is also when it feels like that yeah you can see it's a little x-ray chest k yeah yeah good if you're standing back just work your carrying the antibiotics if they're able to start to flow if you're struggling to get out of bed you you would yeah that's so great you let the jiggle there can you actually got your bit of a that's fine where is my throat yeah it's just some of the tube isn't it yeah it's a bit tricky isn't it but you seem uncomfortable and stiff and yeah yeah seem to be good yeah thank you so you've got you've got your tummy is sore isn't it sore than I was thinking it is I I was gonna scan it with another ct scan is that alright and that showed the patent was there had been yeah so there was an operation more than 1 year after and also complications associated with so just 1 the oral medications yeah okay and is the aim to do that it could happen tonight of course speak to the radiologist now yeah she should have some contrast I think yeah if that's okay and make him yeah make him of moving out of a and e yes I guess you have no idea unfortunately yeah the hospital is in a bad way as I'm sure you know we we'd like to get it out to so I'll walk we thankfully it's not a medical ward so we do have much better access to beds there because it's okay so thankfully all the medical beds in the hospital for we should be able to get another back it would be good I will yeah so you can't even go up to a room to get a post take wardrobe get you over to our acute medical unit and have a post take wardrobe if not I'll bring 1 of the gastroenterologists around in the morning and give you post take you in and try and get you up to that so yeah I think yeah it's actually quite mild so yeah vca is a lot more yeah that's yeah exactly so I guess because it's surgical exactly so that's the other reason to go after that since then we can continue the vca which we won't be able to do on the evening yeah so I think what I think what's realistically gonna happen is your stay here the pharmaceutical companies take you in the clinic yeah exactly okay what's the sort of time I spend usually we manage them conservatively yes but like as I say because of the location of the frustration they usually don't cause any problems problems no no they they usually usually stop people from eating because there's a risk for contamination of a small perforation right but usually they they resolve themselves with thrive yeah like I say anytime it's getting strange for it to be for it to be now cheers but you know frustrating things that you're sleeping sleep and they did a scan in they ordered some I did have another stage refill the lungs mhmm it was like a ct a ct port that sort of falls for me well it was april I had a ct tap mhmm mhmm you've got a niggle in your head don't you mhmm turns out alright fortunately incredibly rapidly progressive I remember talking about the ct scan at the radiology x-ray meeting where we'd actually remember hearing about you in that meeting yeah yeah there wasn't yeah the the radiologist was quite confident that there wasn't anything yeah reviewed it in our mdt and there wasn't anything there but it's I am not pointing fingers no no no I don't I don't I know I I I know that's why I'm to things he's asking me in short well if I was having a sympo does that mean it's not aggressive what's I'd rather hear it not yeah okay so to get go in on some penile therapy is okay is it when was the us again did you tuesday tuesday yeah I think we need to work for in diagnosis the first day just look at what's going on exactly yeah then we can work out what to do yeah then decide on what you need if you have any questions just I'm around and I can can talk you again and stuff yeah so please don't hesitate to come and cry yeah okay do you do you post a gram 8 9 8 9 okay yeah we hand over increasing abdominal pain requiring pca possibly secondary to complication related to ercp versus alternative intra abdominal pathology raised inflammatory markers suggestive of possible cholangitis or alternative intra abdominal pathology plan number 1 intravenous antibiotics number 2 yeah at least I should do it yeah teds number 3 analgesia number 4 iv fluids number 5 ct abdomen and pelvis with contrast vetted with radiologist with thanks the next given on pca not able to come to amu therefore post take ward round in ed this morning and subsequent transfer to allerton ward under the care of the gastroenterologist but if surgical pathology identified on ct scan for referral to them full stop on examination euvolemic moist mucous membranes significant tenderness throughout abdomen firm to touch with percussion tenderness anteriorly chest fills right lower zone crepitations heart sounds normal pulse is regular add to the plan ecg