Transcription - 20260220T 13-24.mp3

Jacqueline maxwell 475052 58 year old lady investigation scheme is blood gas hemoglobin 61 ph 7.35 lactate 1.3 hi registrars is jackie okay or she's just she's on me okay good I hear you've been having some flat tarry stools is that right when did that start oh I think it was full and it should so a couple of weeks ago started then it stopped yeah have you had it before yeah right so you knew a bit about what it might be in yeah might be caused by yeah yeah fine and you've been feeling more weak I understand over the last few days yeah alright and any pain in your chest or feeling short of breath I think I should definitely short of breath okay mhmm not really not much pain okay good and and pain in the tummy at all or nothing like that no not really no no then thinking about over the last few weeks and months how have you been feeling in yourself you've feeling okay a lot just like been feeling weak I just leak in my mouth everything yeah k and you've been started on some blood thinners yeah for a clot in your legs I understand and that's apixaban is it yeah when did you last take that last night last night pardon not this morning but last night what time do you take it around 10:00 10 11:00 yeah okay got it so we're approaching 12 hours aren't we we're over 12 hours I should say and it's quite a bit longer right fine and have you been taking that consistently over the last few weeks you know no you need any anti inflammatories like ibuprofen any steroids prednisolone no no proxime anything like that any medicines in pregabalin pregabalin yeah just that and I just take that what do you take that before it's like my leg your leg and she got I'm still getting numb it's not in my foot in my leg k fine and tell me about your life more generally does anyone live at home with you no I just live at home and what do you do in a normal day tell me all about it well I can't eat much because I can't do the steps you live with a house with steps or a flat with steps yes just a flat steps yeah I'm sorry fine and you can't get out because of the pain in your leg yeah no I've I've not got any railings on on my I'm able to get railings and get it from my from my foot no railings fine yeah so that's keeping my eyes bent down there I'm sorry and how long have you been stuck in the house for well before I got more I was I was in the house for 2 years 2 years yeah because of because of my leg and what operation did you have on your leg I I it was go on just just to to get get the the blood blood flowing through through my legs okay fine so you had some work on that yeah and that's what's up and then you started on the blood thinning medicine after that is that right right have you put a drip in at all dip have you got a drip in no can you know anything like that pop on it you've a dish very good that needs to go for that as well doesn't it I think it does yeah sorry it's alright I'll go put it in for nice regulars and do you is alcohol a part of your life well it used to be used to be tell me about that oh that was years back when I've been in the clinic and when you were drinking alcohol how much were you drinking I'm touching a bottle of cider mhmm a day yeah what kind of bottle are we talking about just 1 of those liter bottles of cider yeah yeah yeah 1 and a half liter bottles of cider yes I'm doing so mhmm but that's been the long term I've been a part of 500 steps how long did you go for yeah how long did you do that for I've tried that for almost 50 years 20 years yeah okay alright and any trouble with the liver or anything like that no no alright good you could go down to your heart if that's okay yeah palmar over here can I touch the tongue is there any pain in the tummy or anything like that and no palmar over here just looking out at the chest if that's okay fair can you please find a new bone for me on the other side please can you just put your hands up like this in here and pop your wrist up like you're stopping traffic keep them down like that fine okay thank you very much have a look on this I will see you have a quick and quick look the symptoms we'll have to get in we'll just start with the ingredients nicely you never have to leave it's the most likely that I'll be put away now no problem thanks so we test everything out and then yeah you've done everything at home good yeah you're not from around here when did you go off west west scotland a man's a a a a a a scotland what wrong good not small section of scotland any pounds in a second stop it land school glasgow yeah fine is that roundabouts where you were in glasgow yeah that's fine and what made you move down here apart from the weather yeah thank you nice trip I'm sorry to give you some blood quite quickly so your blood test that you've had just now shows that your blood counts are quite low we've got 2 more blood tests coming I've spoken to our blood bank about you and they have met you before they've seen some blood from you before so they are able to give up blood for 10 minutes which is obviously great so we're going to pop some fat cells in and then we're going to get some blood from you quite quickly give you the blood quite quickly as well hence the need for a slightly bigger 1 of these to give you quicker blood and get you feeling better and it's definitely black stuff coming out not fresh blood have you vomited any blood yeah we'll just ready for this blood test mhmm so I've got some nice little lumps there let me come around and see if I can put another 1 on the other side as well so we can give you medicine and blood I'll give you a shot some anti acid medicine as well I've got it it in this file there we go so I'll put the syringe in the upper side please okay this side if I just put some of those little sides in and then I'll come up with my machine have a look at your liver see how that looks see if it looks healthy so on this side you allergic to anything no no and on top of the morphine and the pregabalin do you take anything else no nothing else fine ready yeah it got into your vein but it just didn't like a stain sling sharp in there now and it's just a bit of a bruise I should have tried to do that think you're very tired reckon you couldn't make I'm back to you do you know because I I I felt I was a bit nervous because of paramedics yeah but you know paramedics oh well we're not moving are we yeah just make things a little bit easier just try and squeeze this out just so it doesn't give you a terrible bruise alright nice you like jacqueline or do you prefer the shortened version what do you like jackie jackie jackie alright jackie that's what's gonna call you k can you breathe for a quick cold yeah so on examination heart sounds normal chest sounds clear abdomen's soft and nontender no peripheral edema pale no jaundice scattered spider nevi on the chest but no palmar and femur and no no clear evidence of liver disease clinically so past medical history no intravascular surgery following urgent right axilla bifemoral bypass graft for bilateral lower limb ischemia in october 2025 medications list rivaroxaban 2.5 mg twice a day metronidazole gel as directed aspirin 75 mg once a day duloxetine 60 mg once a day promethazine 25 to 50 mg at night chelocalciferol 1000 units once a day lansoprazole 30 mg once per day final stenosis coded august 2024 nondiabetic hyperglycemia anxiety and depression alcohol excess coded 2,002 angular dermatitis coded 2,000 so she was admitted in october 2025 with acute and chronic back pain known to the spinal team in exeter waiting root spinal root injection had an mri which confirmed distal phalanx osteomyelitis with a collection subsequently managed by the vascular surgeons for limb ischemia with the aforementioned bypass graft change it thank you I've done it thank you fine I've pushed for cc bed yep he's on I'm gonna go directly so impression leah's upper gi bleed secondary to aspirin following sorry epixaban following vascular surgery for limb ischemia plan transfuse to units discussion with transfusion lab and blood will be ready within 10 minutes without thanks upper gi endoscopy when resuscitated 1 following resuscitation aim tomorrow discussion with endoscopist to make them aware hello john hello hello the transfuse aiming at stat iv ppi and ppi infusion less endoscopy could be delayed over 24 hours stop doac continue aspirin k see given grafts in situ if hemodynam if further hemodynamic compromise consider earlier endoscopy chase blood test chest x-ray

Medical ST5 Miller Clerking

Presenting Complaint:
Melaena

History of Presenting Complaint:
This 58-year-old lady presented with a 2-week history of black tarry stools. The melaena started approximately 2 weeks ago, stopped briefly, then recurred. Over the last few days she had been feeling increasingly weak and short of breath. She denies chest pain, abdominal pain, nausea or haematemesis.

She is currently taking Apixaban following vascular surgery. Her last dose was taken yesterday at approximately 22:00-23:00. She denies use of NSAIDs or steroids.

Her mobility has been severely limited for approximately 2 years prior to her vascular surgery due to leg pain. She lives in a flat with steps and has been largely housebound as there are no railings to assist her. She reports being unable to manage stairs easily.

She has a significant alcohol history, consuming 1-1.5 litres of cider daily for approximately 20 years. This stopped approximately 5-10 years ago but timeline is unclear.

Past Medical History:
• Vascular surgery - Right axillo-bifemoral bypass graft for bilateral lower limb ischaemia (October 2025)
• Distal phalanx osteomyelitis with collection (October 2025)
• Acute and chronic back pain - known to spinal team in Exeter, awaiting spinal root injection
• Spinal stenosis (coded August 2024)
• Non-diabetic hyperglycaemia
• Anxiety and depression
• Alcohol excess (coded 2002)
• Angular dermatitis (coded 2000)

Drug History:
• Apixaban 2.5mg PO BD
• Aspirin 75mg PO OD
• Lansoprazole 30mg PO OD
• Duloxetine 60mg PO OD
• Pregabalin (dose unclear) PO (frequency unclear)
• Promethazine 25-50mg PO Nocte
• Colecalciferol 1000 units PO OD
• Metronidazole gel topical PRN

Allergy History:
NKDA

Social History:
Lives alone in a flat with steps. 
Housebound for approximately 2 years prior to October 2025 vascular surgery due to leg pain and mobility limitation. 
Ex-drinker - previously consumed 1-1.5 litres cider daily for approximately 20 years, ceased after attending alcohol clinic. 
Significantly limited functional status with impaired activities of daily living due to mobility issues and leg pain.
Ex smoker - 20 pack/year history

On Examination:
Alert. Pale and tired. Not jaundiced.
Observations: Initial venous blood gas - Hb 61, pH 7.35, Lactate 1.3
• Cardiovascular: Heart sounds normal. No peripheral oedema. No palmar erythema. Scattered spider naevi on chest but no clear clinical evidence of chronic liver disease
• Respiratory: Chest clear to auscultation
• Abdomen: Soft, non-tender throughout. No organomegaly palpable
• Skin: Pale. Scattered spider naevi on chest. No jaundice
• Other: No asterixis

Investigations:
• Venous blood gas (26/02/26): Hb 61, pH 7.35, Lactate 1.3
• Further blood tests pending
• Chest X-ray requested

Impression:
Upper gastrointestinal bleed secondary to dual antiplatelet/anticoagulant therapy (Apixaban and Aspirin) following vascular surgery for limb ischaemia
Most likely peptic due to aspirin use - alcohol excess makes liver disease a possibility but no clinical evidence of portal hypertension.

Management Plan:
1. Urgent transfusion of 2 units packed red cells - blood available within 10 minutes
2. Large bore IV cannula
3. IV PPI stat followed by PPI infusion
4. Stop Apixaban temporarily. Continue Aspirin given vascular graft
5. Upper GI endoscopy when adequately resuscitated - aim for tomorrow. If haemodynamic compromise, consider earlier endoscopy
6. Chase pending blood tests including full blood count, clotting screen, renal function, liver function
7. Review chest X-ray when available
8. Allerton bed
9. TEP full escalation.

Summary

Investigations

Plans