Physician's Assistant

Patient Details

Issues review (293 days ago 18:03)

Issues review Tue 17 June 2025 18:03

Last Modified: 293 days ago

MRN:

Content:

Issues:
1. Acute deterioration in liver function tests with jaundice
- Alkaline phosphatase risen from 180 to 1000 over one week
- Bilirubin increased from 8 to 47 over 3 days
- ALT elevated from 15 to 215
- Patient now clinically jaundiced (new onset)
- No abdominal symptoms
- Pattern consistent with cholestasis

2. Scheduled for urgent lower limb bypass surgery tomorrow morning
- Chronic limb ischaemia requiring limb salvage surgery
- Common femoral to popliteal artery bypass planned
- First on theatre list at 09:00-09:30
- 4-hour procedure under general anaesthetic

Background:
Patient with known hypertension and iron deficiency anaemia. Recently received Ferinject infusion yesterday. LFTs were slightly elevated prior to iron infusion. Current infection screen negative with normal white cell count, CRP 30, normal renal function.

Impression:
Likely choledocholithiasis (ductal stone) causing obstructive jaundice in patient requiring urgent limb salvage surgery

Plan:
1. Hepatology review with bedside ultrasound scan tonight
2. Consider CT abdomen if ultrasound inconclusive
3. Anaesthetic team discussion regarding jaundiced patient for GA
4. Proceed with limb bypass surgery as planned - limb salvage priority
5. Post-operative ERCP if ductal stone confirmed
6. HPB surgical referral for consideration of cholecystectomy

Field Clipboard (for EPR paste)

Builds copy buttons from the headings currently in the note, and also lets you copy the entire note.

Summary:

Investigations:

Tasks

Feedback

Rapidreview (293 days ago 20:00)

Rapidreview Tue 17 June 2025 20:00

Last Modified: 293 days ago

MRN:

Content:

HEPATOLOGY CONSULTATION

Patient: John Ottarall
MRN: A169808
Location: Clearbrook Ward
Date: 17/06/2025
Time: 20:00
Consultant: Dr Mel (Hepatology)

INDICATION:
Abdominal ultrasound requested for deranged liver function tests.

HISTORY:
Patient reports no abdominal pain. Denies significant alcohol consumption - reports occasional 1-2 drinks per week. No known diabetes. Past medical history includes CABG and longstanding reflux disease managed medically. Currently pre-operative for vascular bypass surgery scheduled for tomorrow due to poor leg circulation and non-healing wound.

CURRENT MEDICATIONS:
IV iron (administered this afternoon)
Reflux medication (unspecified)
Morphine as required for leg pain

ALLERGIES:
None reported

EXAMINATION:
Patient appears mildly jaundiced. Abdominal ultrasound performed but views significantly limited due to recent food intake and hepatic steatosis preventing adequate ultrasound wave penetration despite firm pressure.

ULTRASOUND FINDINGS:
- Liver contour appears regular
- Evidence of fatty infiltration (hepatic steatosis)
- Gallbladder visualisation poor - appears small and contracted
- Unable to adequately assess bile ducts due to poor acoustic windows
- No clear stones identified on this study

ASSESSMENT:
Deranged liver function tests with biochemical pattern suggestive of possible choledocholithiasis. Clinical jaundice present. Ultrasound non-diagnostic due to hepatic steatosis and recent food intake.

PLAN:
1. Additional blood tests to exclude other causes of hepatitis (viral screen, autoimmune markers)
2. Urgent CT abdomen to assess for choledocholithiasis
3. Discussion with surgical and anaesthetic teams regarding fitness for planned vascular surgery given jaundice
4. If choledocholithiasis confirmed, options include:
   - Surgical exploration and choledochotomy
   - ERCP with sphincterotomy and stone extraction

Patient counselled regarding findings and potential treatment options. Explained that jaundice may complicate planned surgery and require investigation first.

Dr Mel
Consultant Hepatologist

Field Clipboard (for EPR paste)

Builds copy buttons from the headings currently in the note, and also lets you copy the entire note.

Summary:

Investigations: