So next patient is julie armstrong 961810 74 year old lady investigations ggt 2 7 4 ast 2 4 4 eosinase normal creatinine 43 at baseline lfts bilirubin 17 alp 465 alt 382 inr 0.9 full blood count normal immunoglobulins normal ultrasound abdomen awaited presenting complaint lethargy, weakness, reduced oral intake for 6 months past medical history hypertension left caudate nucleus stroke 20 25 may osteoarthritis of knee 2012 current repeat medications mirtazapine 15 mg once a day laxido 1 or sausages as required ramipril 2.5 mg once a day senna 7.5 mg 2 15 mg at night omeprazole 20 mg once a day amlodipine 10 mg once a day atorvastatin 80 mg once a day aspirin 75 mg once a day allergies to tetanus vaccine only doctors 1 of the liver doctors how are you good to be rob with you nice to you rob I haven't guessed as much nice to meet you as well hi rob can you hear me we're moving over his phone no worries how are you we're over 1 yeah good I've been having a read over everything and looking at your results but I'd great to hear it'd be great to hear about how you're feeling she's she's doing yeah what symptoms have been like tell me all about it oh really it's warm it for the last couple of days basically it was julia has been eating and drinking she hasn't been feeling well at this but yesterday all she wanted to do was basically either lay in bed or or sit in a chair with her eyes closed got very pale lethargic and all over the place so I rang a doctor I rang doctors they sent an ambulance right anywhere and apparently the blood test from last night in casualty shows a high yeah something's doubled in 3 months the liver tests have gone up yeah something's doubled in 3 months that's what they were concerned about and then more blood taken this morning so here we are yeah and I've seen the results of those tests which are very similar to the ones in ae yeah that show raised levels of liver tests not jaundice which is always good it makes it look like the bile ducts around the liver are a bit unhappy and that can be had your abdominal ultrasound scan already yes that was done early on I haven't seen the results yet I'm just the let's put it this way sunday was a day which was feeling really tired monday wasn't too bad because the physios came in with her and they had a good conversation with her as well so we'll call monday a good day and yesterday was a terrible day not a good day at all yeah and has it been going on more than that more than since sunday lackaging and tired not really well julie had a couple of really bad nosebleeds the prior week on the left hand side and I'm talking 2 hours at a time our own doctor came in and tried to sort that out although we ended up casually once but that seemed to settle down so we were saving the last week or so whatsoever there any other symptoms at all any pain in the tummy not any pain in the tummy but the pain in the abdomen you have had lower tummy pain yeah okay can where can you. To the where it is exactly well the the dot quite low down that I know in the back the pain for well I'm in the pain you haven't any pain sorry I thought you said you had some pain yeah see I haven't had any pain yeah diagnosis that did the diagnosis of smiling right says I have okay I see when you had the scan yeah you were in a bit of pain but you haven't had any pain at rest I understand noticed any other symptoms have you been able to eat very well and is that because you lack the appetite no not the appetite have you tried eating anything I've tried a few tried a few I've tried a bit of sandwiches or you know a little bit of fish and carbs it doesn't feel like eating or drinking for that matter any fevers at all no no shivering shaking hot or cold no haven't noticed any changes like no good and you haven't got any other observations here about it that's no tell me about you more generally you walk with a stick no that's me you walk with a stick it's me with a knee yeah that's me with a knee so you walk all by yourself you guys live together yeah no judy I was gonna walk in mine at home fine the walker we've got a trolley and dolphin but nothing with us today because we ended up in the ambulance I see fine so you use a walker at home yes you live in a house or a bungalow house at the moment yeah we're hoping to move to to a ground floor and 2 bedroom flats which is access because at the moment we've got stairs but julie is not upstairs we've brought the bed downstairs because the stairs are rather old fashioned style steep so we've moved her downstairs there's no way she's banned from upstairs I see fine upstairs is your man getting up yeah upstairs is her eye either way mhmm but over the last few days I've noticed that my her her urine the procedure changed color okay it went away darker dark urine and your stool stools yeah yeah no pale no opposite way around dark as well last yes no didn't didn't empty it yesterday because it didn't go so late on sunday very dark very dark and dark stools and dark urine what's the color of the urine is it like cocoa dark yellow dark yellow yeah dark yellow like an orange yellow yeah but not like cocoa no good that's good no I understand what you mean there yeah yeah and any weight loss is pretty simple cool well I suppose since it's stroke you've probably lost a bit of stomach but that could be to do with a stroke and being inactive and going as what else yeah yeah not eating as much not active at all we used to walk the dog every day and and got on the blood else and what do you what do you do at the moment for yourself not not to be in with everything we'll get a carer no we'll stop the carer because judy was having it just for personal hygiene I see and now she's able to wash herself and dress herself great so that was an improvement getting better so once we hopefully move to a level floor access I can get her out yeah because at the moment I've got 2 deep steps to get her out the house I see and then we stop yeah the the move should take place in the next couple of weeks but you could get out of house like you're out of the house today yeah we we we yeah we'll get it out we will get it out yeah I understand yeah right do you still are you allergic to anything no no it's fine I've seen your regular medicines that you take and taking tablets at the best of times can I have a look at your hands and listen to your chest is that alright thank you very much turn them over for me thank you k I've never been done no can I feel your tummy do you mind if I lay down the bed a bit quickly might you be able to lay down I'm gonna lay back and I'll lay you back like that is that alright do want me to help you with your legs that's that's lovely I can lay the bed flat instead of you sliding down okay alright yeah we can put your bag up in the book put the back up in the bowl get you comfortable in a minute can I have a look at your tummy if you like mhmm thank you no operations on the tummy so the ultrasound will be really helpful and once that comes back we can have a much better idea of what's going on but certainly as I say the blood tests look like the bile ducts around the liver are inflamed from the blood that can be from stones passing through the duct and irritating them things like gallstones I'd usually expect you to have pain but it can sometimes have not much pain as a small bit of stone passes there can be other things blocking the duct like narrowings in the bile duct whether they're from inside the bile duct or from outside the bile duct the ultrasound scan will really help us once we've got that report the remainder of the tests don't make you look like you've got an infection in the bile ducts or anything like that which is good but I think it's gonna be very difficult well once we've got some imaging once we've got this report we'll be able to tell a lot more about what's going on certainly I can say at the moment that you seem very well but your bile duct's definitely look like that may well be what's making you feel so rotten you're generally lethargic not very good yourself so I'll have a look now on the computer and if there's scans back I'll come and tell you what it should be alright yeah fine yeah for a while you oh come on impression kilo static lfts mixed picture actually anemia or jaundice on examination limited communication from patient post stroke patient said patient's husband says at baseline appears lethargic, tired full stop pale full stop mildly obese abdomen but soft and nontender throughout with this feeling of upper abdominal fullness however no discrete palpable mass chest clear heart sounds ejection systolic murmur radiation to the carotids no peripheral edema