So next patient is douglas atkins 1085798 past medical history spinal stenosis primary open angle glaucoma balonic polyp july 2024 type 2 diabetes mellitus with preproliferative diabetic retinopathy and ckd stage 3 diverticular disease aortic valve stenosis ischemic heart disease open brackets nstemi 20 19 close brackets diabetic neuropathy hypertension hey you alright sorry to pump no what's up what am I doing no just note nothing you're not doing anything you've a cancellation amazing it's something I'm not doing even better thank you great that's for a different patient so just ignore that add to the aortic stenosis after the history open brackets echocardiogram august 2025 moderate investigations ultrasound abdomen july 2025 29 millimeter hypoechoic avascular area seen in the gallbladder could represent gallbladder polyp or adherent sludge or gallstone definitely limited scan due to limited mobility where seen liver in normal in size but an increase in echogenicity can be seen abducts and vasculature no ascites no splenomegaly <\n> Noninvasive liver screening in 2024 negative for viral or autoimmune liver disease normal ferritin full stop <\n> Liver function tests august 2025 alp 131 normal bilirubin lfts june 2025 noted alp with normal bilirubin most recent alt july '15 cheers to give you a bit more room much no worries at all I'm doctor miller I'm an electrolate gastroenterologist nice to meet you yeah how are you have a and we can shake hands after because we need to sit yep yeah checking hello you missus atkins hi I'm yeah nice to meet you to meet you missus atkins how are you I'm not too bad thank you I'm glad not too bad I've you wanted us oh I'd love that yeah thank you very much how what do you understand about being referred to liver clinic I'm 1 of the liver doctors well I don't really know why I'm here to be honest fair enough I guess I count that much I thought you follow-up from last last year's appoint I I came last year mhmm yeah you saw your gp yeah back in when was it referred on in june 2025 I had a conversation I didn't see anybody okay you had a conversation I don't see anybody these days well it's nice to see you yeah it's not well yeah we're we're lucky that we get to see people in person yeah so your gp was worried about some elevated liver tests yeah back in june mhmm did you have any pain at that time why did you see your gp I mean the later blood tests have all come back clear they have it's true yeah they've all got better and it was because I got problems from the back I got 2 vertebrae that have come together and trapped all the nerves in my back it's anastomosis I mean I've had it for years it's got almost so it must be terrible I see you see the spinal surgeons are they gonna do anything about it dentful because they're currently giving me an operation because of my heart I'm waiting for them to come back they were in additions plymouth they were checking with the care to get an latest update yeah and I saw you have an echocardiogram back in august yeah they scanned the heart which showed it was moderate not severe uriarteric that last week that was last week yeah yeah fine august that totally unrelated yeah fine okay not to assess your fitness and your options was totally unrelated to my heart okay fine I was taken into n because I had a bad reaction from an eye drop I read that and the consultant warned me that if I got chest pain shortness of breath I stopped taking it and go to hospital fine well I waited for an hour or so before the dead way spoke to 111 and explained I had this letter from the consultant and nobody gave you an ambulance and so nobody about nobody thought anywhere along the line it was the eye drops so they were checking my heart all the time made a blood test I had an x-ray had a scan and then in the end you're fine you stop the iron serum you're can react to it I'll react to it fine okay you're that kind of person I mean they've never heard of it before that's that's why I have it mhmm but the doctor did say that the heart is no different than what it was sort of yeah february yeah that's good yeah that was good from that. Of view and what do you understand about the liver test did anyone explain that to you or anything no they were quite high back in june now they got better yeah which is this is most recently could you because of your back couldn't lie on your back for yeah I I can't have the scan because I can't lie on the back of the ultrasound scan sorry is that an ultrasound scan or a different scan I mean the 1 on the scan on the gallbladder liver it wasn't the liver they were worried about it more the gallbladder so they but I can't land it back for more than 2 or 3 minutes it's blepharic and relaxed and they keep trying in on painkillers when I say they aren't working morphine is fine it really does bum people up that morphine is something wrong and diarrhoea and when I was in hospital last week they gave me some morphine intravenous and within a few hours I got some pushing it back I didn't want to be sick it was just being pushed back up the next thing is they're trying me on morphine patches I've got them but I wanted to speak to the doctor about it which I a job to speak to the doctors I did eventually and I had a chat with him I was hoping to pick it up tomorrow because it would tuesday I'd spoken about it so it would be wednesday morning for the prescription to to clinic something to control the sickness and they'd wonder whether because I'm a bit sluggish by the if they gave me a laxative we may make it I reckon that would be the thing to do they would do that obviously as well as liver doctors we're bowel doctors so it sounds like it sounds like you have opiate induced constipation because of the morphine it's not that I'm a bit like it all the time I go 2 or 3 times without going and then I go quite regular but I usually get a bit of diarrhoea on the end of it and you have diverticular disease don't you some outpouchings in the bowel that we saw on a scan that you had before and that can also upset upset the bowel habit certainly yeah and it does predispose some people to having these episodic loose stools yeah yeah but what you described certainly sounds like the opiates the morphine is bugging you up yeah and that having a laxative alongside it would be a thing to do something like senna at night to see what works like senacot you can buy it over the counter yeah that would be the thing yeah to try and improve your balance basically it'd be nice to get something that killed the pain that didn't upset the rest of me I know I know all our treatments have side effects unfortunately I wish there was something some magic thing that we could do as I said to the doctor once most of what you'd prescribe and kill you it's true anything can and the right dose can't it but in terms of your liver you had that ultrasound scan yeah it showed there was a tiny bit of fat in your liver yeah but you've had diabetes for a long time and we know that's a risk factor for fat deficiency in the liver is that type 1 diabetes that you have yeah fine and you take insulin for that yeah fine so that will predispose people to having fat in the liver and if you've had diabetes for that long yeah it's very likely you develop some fat in the liver I think probably most 86 year olds will have some fat in the liver I don't think that's anything to worry about there's that tiny area in the gallbladder they said it could be a polyp in the gallbladder that's when you get a little outpouching in the gallbladder wall we worry about those because over decades they can turn to cancer yeah so some people have their gallbladder taken out because of gallbladder polyps however they wouldn't usually irritate the liver tests so I wonder whether it's actually a small stone that you had there that you've now passed they did wonder whether it's because of the pain early on I was taking quite intensive courses of paracetamol and when they stopped it the liver test started to come back better the amitriptyline and paracetamol how much paracetamol were you taking I was taking about 6 a day and the amitriptyline I was taking 6 500 mg tablets a day and the amitriptyline 3 they've allowed me to go back on to the amitriptyline taking 2 a day very good yeah that's very unlikely to cause liver test problems I'm not really going back on to paracetamol but I need to do something as long as you stick to the right dose paracetamol shouldn't be a problem and the pattern of the liver test doesn't look like a paracetamol liver problem it looks like it more like a gallbladder problem yeah if that makes sense mhmm I suspect what's happened is you had a small stone yeah which we detected on our ultrasound scan and you passed that stone and that's why your liver tests have got better yeah that's option 1 option 2 is it's a drug induced problem from the amitriptyline or the paracetamol but I think that's less likely and time will tell as you come back on the amitriptyline yeah if your liver tests go off again yeah then we know been taking that for what couple of weeks 2 3 weeks 2 3 weeks should we retest your liver test today then and we'll see whether the amitriptyline is irritating things yeah yeah in the context of whether you've got a stone or whether you've got a polyp I don't think thinking about taking your gallbladder out is the right thing to do I think it's unlikely to cause you any problems it doesn't sound so you would get reoperation exactly right for the same reason why they don't want to get you he said I don't know any anaesthetist who touched you that was his exact words weren't there I feel the same I think that it would be unlikely that that would be the right thing to it would have to be a life or death situation before they and the settings mhmm then that does leave you dealing with that back but I think that's your number 1 problem I don't think the liver tests are your problem no the back's a problem at the moment I mean it's been a bit easier this week I take a couple of paracetamol and a lot yeah you know that's what I took was 2 mhmm well very good and when you say you're taking 6 a day was that 2 tablets 6 times a day or was that 1 tablet 6 times taking those are 2 and the rest were ones those ones fine you wouldn't have overdosed no no yeah I tried not to take them to be honest of course yeah no no 1 take likes taking tablets and you're only on the insulin and the amitriptyline yeah and nothing else really any eye drops drops yeah okay yeah alright so in terms of the liver what should we do I suggest we get some blood tests today yeah look at how the liver is on the amitriptyline mhmm if it's all normal then I think we put the whole thing to bed yeah and say this is not your problem yeah and I think that the back is your number 1 problem and getting good painkillers on board to help you move around is the most important thing what do you suggest I mean regular paracetamol I think is good 1 g 4 times a day which is 2 tablets 4 times a day just carrying that on yeah and then I think this fentanyl patch could be really good yeah but as long as you have some senokot as long as I can in the evenings hold myself together exactly yeah I reckon something like senecot not something like laxido yeah laxido makes things very wet yeah but senecot improves the movement of the bowel yeah so it helps if the bowel is slowed from opiates the senecot will improve the speed yeah yeah so I think that would be really helpful mean take 1 daily exactly at night 7.5 mg they come in you could take 2 even if you needed to yeah yeah to prevent that it sounds like you're already a little bit constipated so I would probably take 2 yeah take 15 mg at night yeah so get some regular seneca on board get on your fentanyl patch and get your pain under control that's the number 1 thing yeah we'll check your test today and make sure that the amitriptyline hasn't upset the liver test but I don't think it will have yeah and if it's and then if that's all fine then we're saying this is either a polyp or a stone either way I don't think rushing in to do anything about it is the right thing yeah carry on and try and get your pain sorted yeah yeah that sound alright I mean that's that is the main problem I mean some days I when it's sat like this I'm free of pain when I lay down in bed I gotta try and like I can't remember I lie on the sides and even that's getting uncomfortable yeah I'm sorry sitting like this is the most comfortable the worst is standing when the pressure you're putting straight pressure on it have you ever seen a pain specialist well this is the you see I went back to the physio people here yeah who referred me and I've been told she had been referred to plymouth for the operation I got a ring to speak to the consultant and recommend anything further if you don't do an operation not coming back here but I but it doesn't sound like they're going to operate does it sorry it doesn't sound like they're going to do an operation when he gets a reply from cartier he's putting a letter to me and then I've got to ask him well what's the other options now apart from painkillers like pain management can you refer me back to torobey for that yeah I don't see why you couldn't have that in the lead up to an operation if it makes you more comfortable but I can't no it doesn't make any sense I don't know where to go to ask that question well I can ask the team here to refer you for that or if you can ask the spinal surgeon to refer you I'd be very very grateful of course I'll try because that's your number 1 thing it's not my area of expertise but that's your problem I'm grateful for that yeah it's a question of I know there's pain management clinics but how would you answer them once you're in the door it's really good they're great which story you trying to knock on I was hoping going back to physiotherapy they would have said well in the meantime we'll refer you we'll try this to you you know oh sorry yeah for I mean I've tried I've tried I did try I spoke to an osteopath mhmm here and I I sent her the scandal brought in her back and she said you'd be wasting your money she said come and see me she said she said don't you're gonna be able to fix don't want to do that that's very kind isn't it you know I mean she was very open and honest lady and she came and recommended from somebody else which was good you know yeah fine with somebody else okay sir so I'll get some blood tests today yeah I'll refer you to the pain team ask your gp to add the senecol onto your repeat prescriptions for the opiates you're gonna have I mean he's prescribed some sort of ative now I don't know what it is till I pick it up tomorrow yeah we'll see what it is hopefully it'll be that yeah okay yeah alright yeah blood tests are and the blood tests they'll do them here just in the waiting room not done in levels yeah they'll do them up in the bowels yeah yeah not done in the bowels so it's just about the fun no don't worry just through the waiting room yeah yeah and then go right yeah that's where the blood test where I was weighed asked where you were weighed exactly turn right and the blood tests are there there's a big sign that says blood test you won't miss it yeah okay alright that's lovely okay any questions or anything I've forgotten sorry any questions or anything I've forgotten I I don't think so you've answered a lot I mean I didn't know why I was here now I understand more okay what you've talked to me again in conjunction with what the doctor said at the beginning it'd make a lot more sense it would take a long time to get here I'm sorry I've had these bouts of diarrheal I used to have diarrheal for up to 10 days at a time because they did all the tests and nothing then I did a private and since I cut those out I've been much much better and wheat is the main problem but funny enough the person I went to see recommended a banana sourdough bread which is a wheat based product yeah it is but that's not that doesn't cause trouble I mean when I go out anywhere I say gluten free dairy free because people understand that word for me I understand that what what I'm trying to say wheat lactose yes well thank you very much indeed it's pleasure to meet you I look forward to seeing your blood tests and I'll write to you today and look at the results of the test thank been so thankful today you 0.5 millimeter hypoechoic avascular areas seen in adherence tee where seen liver in normal in size but an increase in echogenicity consist noninvasive liver screening 1 normal bilirubin full stop lfts june 2025 noted alp 467 with normal bilirubin most recent alt july '15 can have a diagnosis please cholestatic lfts now resolved differential diagnosis includes past stone and drug induced liver injury secondary to amitriptyline plan number 1 blood test today now has restarted amitriptyline number 2 no intervention planned regarding possible gallbladder polyp / stone number 3 senna 7.5 to 15 mg once nightly to be added to repeat prescriptions to be taken alongside fentanyl patch prescribed from gp please number next no gastroenterology follow-up planned had the pleasure of meeting mister atkins on behalf of doctor neil in hepatology clinic today full stop the consultation was face to face and he was accompanied by his wife full stop <\n\n> His mobility is particularly challenging for him due to his spinal stenosis and he's in a significant amount of pain with this full stop I'm happy to hear that you've started him on a fentanyl patch which I hope will be very beneficial to him full stop he's previously had reactions to morphine in the way of constipation and overflow diarrhea and I'd suggest taking some senecot alongside the fentanyl patch in order to ensure that he tolerates this in order to achieve adequate pain control full stop if he continues to have difficulty then I wonder whether him seeing the pain team would be a sensible next step full stop <\n\n> We were able to discuss that his liver function tests over 3 months ago back in or his liver function tests back in june were and may were elevated in a pattern consistent with biliary irritation such as a stone full stop his ultrasound scan showed what may represent a stone and what may represent a small gallbladder polyp full stop <\n\n> What is particularly reassuring is that his liver function tests have completely resolved now and are back to normal full stop he didn't have any pain at that time full stop <\n\n> We discussed that his elevated liver test could be due to a stone passing through the ducts or maybe due to a drug induced liver injury secondary to the amitriptyline he was taking full stop I note that the amitriptyline has stopped and the lfts have returned to normal full stop he's been restarting on 2 weeks ago and so we plan to recheck the liver function test today to ensure that a drug induced liver injury is not the cause of his lfts full stop <\n\n> If his liver tests remain normal on the amitriptyline then I would not recommend further scans or intervention regarding the potential for stones or gallbladder polyps as a cause of these deranged lfts full stop his spinal stenosis is number 1 problem and pain control with this should be our priority full stop in his wider health given his wider health he would not be a candidate for operative management in the form of cholecystectomy and so surveillance would not be indicated here full stop <\n\n> I've not made any plans to see him again in hepatology clinic but will write with the results of the blood tests full stop heals thanks very much