So next patient is allison dayman 749298 hello I'm matt I'm john I'm 1 of the gastroenterologists I'm doctor neil we just all rotate at the september so I was just working in derryford before oh right like a couple weeks ago you know I've been down I've just been down there have you oh good all over the place yeah I know I can see you are when did you go down there it would have been august sometime I think I saw katie oh lovely yeah yeah and katie that was lovely yeah how is she yeah she's good yeah she's how did what did she think of you what did she say fine yeah we just had a chat really great and I had a she's good at lying too yeah yeah and I've got another 1 with her coming up as a birmingham amazing for a transplant well no I've I've kind of had that I'm I'm onto them now great you've had the transfer assessment then because I don't have any letters from birmingham oh god great because the letters have gone to well the letters have all gone to darafed they haven't sent it to us alright yeah no they they are not listed simply because they don't feel that I'm I need to have a transport at the moment but they've effectively said we'll put you in the system so that we'll take you on if things get worse amazing that's the best outcome isn't it because you don't need to have an operation a transplant but if things get worse and they're fantastic I mean everybody's always had all fantastic looking so thank you for that everybody's laughing anyhow but it's quite a quite a hospice it really is yeah yeah yeah you think derrif is big and then you go out there and you go it's 6 months yeah so you went so you're going up to birmingham on the sixteenth on the sixteenth to check-in with them yeah yeah last time I went must have been about 6 months it's the same sort of thing as this I'll go to see a panel so I get to see a nutritionist I get a womb so that's alright and then so 6 months ago is when you had your transplant assessment and they haven't missed you that day or anything it was kind I had a transplant assessment down at no no I've had 1 since then okay you had another 1 since then another 1 mhmm and at that. They felt that I should I think I had covid I had covid 3 mhmm really bad time I had a bit it just all kept when that's your coping mechanism yes when life stresses get on top of you it's completely like this is the good thing about talking to yeah yeah also we've put in place a lot of beauty with mom so that that's they've helped you do that up in birmingham no they haven't really it's just circumstances right you know and anyway that's so they put me at derriford they put me forward to see yeah so this would be the first okay fine so maybe a year ago you had a transplant assessment but they made the results of the assessment it was hilarious really I I was expecting this panel of people you know they went to this room and this guy came and collected me very young like you came in he said like come on in and help and I thought we were waiting for the other 2 so we're just sitting there chatting like you and I are yeah yeah and then at the end of it he said well don't feel that you're ready for it I thought oh god that was a that was a consultation what are the best consultations on there you feel like you just haven't checked yeah yeah yeah great yeah so so they don't think you need 1 but they would be happy to do it if needed exactly great that's the thing well he did that he was the first oh I've got a guy and I saw testing yeah alcohol testing mhmm on lactone mhmm and she wanted me to stop it as well and my my lady I was talking to her about that and she said well I'm wrong so I went I came back and I thought low dose I phoned her 50 because I felt that it wasn't got the spirochic yeah and I couldn't go through this course know and the air force yeah not swelling swelling up up no no no no you to learn to manage mhmm everything because that's the thing when you're cared for by all these teams you're the person advocating for your health it's difficult isn't it yeah yeah it is difficult it is difficult but it's fascinating mhmm 1 of the things they did say at birmingham was they put me on that's good isn't it it's excellent and it is 40% of anything that I should be eating or wounded or fat but we all we shouldn't we all be recommending yeah but they've put me on these drinks and that's that's weird because mondays you can almost feel I'm not being religious about it right so think it's just just talking the amount of protein you need when you're decompensated is huge isn't it it's you know yeah far more than any any diet without supplementation can really achieve like 1.5 grams of protein kilogram so say you weigh 70 kg yeah yeah get a 100 and so grams of protein which is a lot difficult to achieve with chicken and alone yeah and and not a lot of good meat oh great so that's good yeah yeah and I like again I think that's my body telling you what you need you about your body knows doesn't it it's amazing oh yes yes mhmm for sure and whereabouts are you you're in like in turkey nothing in turkey yes okay fine great so going to therapy is not too much of a burden but going no to it's well don't make sure okay I'm I'm we've we've gone on a train now mhmm okay think last time I decided yeah that's 1 good thing isn't it to be fair sometimes you think oh at least I'm in la but yeah I mean it it does cost because you go up there they offer accommodation and things like that no no no good I think they do at darefoot people that travel from a long way yes oh yeah that's a fantastic no I haven't been in there no oh you wanna want to go along there the the accommodation is nice oh yes they're fantastic oh good I mean we always whenever we do have to go there and supposedly for because of the work they do yeah great and that's actually thing birmingham's a different place so it's no good and I like reading and so nicely holding on the way to you all that way isn't it and now that I know where I'm going and it's getting I'm I'm getting but then I'm thinking about I think our role here mhmm you're having these transplant assessments but we're our role is to manage the basics in your care right so in terms of surveillance for passing and fasanoma I think that you your last scan was in july 24 I can't see you've had 1 since then you should probably have an ultrasound scan if you've not had 1 in derriford or birmingham over the last 6 ultrasound imaging fine maybe that was a year ago then no that was the last time that was the last time fine because he's right I think that he because he found okay and I know that I have got lesions on my my liver I wrote a letter I got a copy from ultrasound an mri scan mri scan mhmm okay be done fine here but I no sorry I haven't got that yeah when I spoke to katie I wondered whether maybe they'd had a discussion at this and and and was actually a wordy there maybe yeah fine I had it I know that's the impression that I've got I will chat to doctor neil and I'll copy the I'll ask katie basically and say what 's what do you want to do about that and have you got the letters from birmingham to send through to us so we can at least try and collect everything week as well any help in birmingham exactly so I'll try and I'll try and work it out we'll work it out and make sure that you've had some sort of surveillance and if they do need an mri scan I'll arrange it for you here yeah and I I feel perfectly okay I managed to avoid man flu everybody in my household except for mom and I went down boom and I thought oh god here we go and I didn't get it oh great that's good brilliant so great so the spironolactone ankles haven't swollen up yeah no no they're going to they've gone down there of course I'm pleased to have any other sort of decompensation any fluid in the tummy that you've noticed no the last that's why katie said to take come off it when I was up at birmingham checked me so there's no fluid there obviously you're a son of a choice well we've got but it is a swimming pool I've just but but then running out and down after mum's stairs and what have you feel like I'm getting a bit okay yeah not really used to exercise so much when I was younger I feel like I do everyone goes through phases I think you get motivated and then the weather changes and it turns like this and you get yeah I know we are actually getting a break oh look really it's it's is lovely that was the other thing the last time on on I had been like we had 2 holidays this year we've had 1 in 1 in in 1 2 people brilliant it's just been a wreck okay shame I don't care yeah it'll be beautiful anyway yeah can I have a quick look at you do you mind looking forward you still do your tummy and look at your hands is that alright yeah that's the whole range yeah and then I will ask some blood tests every day if that's okay yeah that's fine going of course and then I'll work out the mri thing and I'll put your needle on auto does sound okay perfect that's great you being okay at night oh I sleep well that's yeah hands out in front of you like this that's lucky do you drive yes great and you made in hospital cleaning but not out yeah no not out that's pretty cool yeah in hand no in hospital I can't I think that a lot I think that yeah I realize I've changed your jaundice and you're right you know yeah I've seen that I've had that for a long time I mean they're just not getting better or worse or anything it it varies day to day yeah mhmm I think it's got marginal effect it's certainly since doctor neil first said about me going down to derriford for the okay good so it it really was quite good but I can't seem to shift it and I I don't know once again I'll if there was anything I could do about it don't know mhmm mhmm I think getting the liver working better is mhmm is the is gonna be the treatment for that it doesn't look like you've got any anything else causing you to have jaundice would be some of that so it's a bit of I'm going down this what can I I've changed that a little bit yeah it does you know that I mean in babies that's what they do isn't it you do phototherapy and it may well break down the jaundice in the blood it it may temporalize things for them but yeah it's a different type of jaundice so it only breaks down when you've when you've got a certain type of jaundice you've got a different kind of jaundice so the bilirubin that's building up in the you is is conjugated because it's been it's gone through the liver yeah and that doesn't break down with sunlight okay but bilirubin that hasn't gone through the liver does yeah so okay it works well for babies when they have they break down the blood cells when they come out of the womb which does happen very commonly and that would break down that unconjugated habit of bleeding well I was a 1 trees everyone would be on top of that yeah 1 of the things that they they put me on was the d3 I work for think I'm on that thing just looking at them anyway I did this self test and 1 of the things that came out and I I happened to mention it that was done in zaraford mhmm with professor cranick yep and he put me on some deep tablets great he he actually did what do they call it when they load you on first yeah 6 weeks of a 6 week course of his week and then once a week then they'll be on to the tablet half life that's right yeah brilliant and I don't know what I think that made me feel a bit better actually good yeah well funny enough my my mom's been everybody on that these days I'm sure yeah so yeah so I think everything all the other medication is exactly the same gonna look at your ankles as well just to make sure you haven't got any flu sorry I have got that's alright what do you want I've got I have started wearing brusher socks yeah yeah yeah my mom's got it and my sister's got it both my sisters are have that it's called lymphedema or it's only a very slight amount isn't it it's it's gone down lucy I don't think it's gone completely about a week ago it was quite high if slightly dehydrating you with this spironolactone it can make the liver appear worse so I wonder whether we see what your blood tests are like today yeah if your jaundice markers are further down which I think they will be because looking at your eyes I don't think you're gonna have a bilirubin of 90 if it's better off the spiral then I'd suggest we tolerate a tiny bit of ankle swelling with better jaundice levels but we know that if we develop ascites we can think again but I think actually I think it could be the right thing to do to have a tiny bit of ankle swelling with better jaundice markers as long as your sinuses come back they're comfortable good they don't cause me any hassles it get big enough so before you cough you cough in your shoes yes and yeah so and can I manage that myself yeah you can if you want to that's absolutely fine I mean you might not know whether you've developed ascites without having a scan yeah but certainly in terms of the fluid on the on the left it's the sound isn't it yeah I've done that do you feel like you I haven't got it at the moment getting gurgling sound or no it's it's when you do that yeah fine and it's that hollow sound mhmm yeah yeah hollow is full of air which is what we want when it's dull and particularly when it moves around that's when we okay when we think there might be ascites there but I must say I think if you did a if you did a study with how good we are at detecting that I don't think we're probably very much better with a scan does that make sense I think we're our tests are much better than our than us probably let's have a look at your kidney function now you're off the spironolactone I'll get your liver function tests and make sure see what your jaundice looks like I think that's your asd as well when I first talked to birmingham they've got I mean they've got obviously people worried about you know bad people yeah there's this 1 guy he's called ted oh yeah he's been there forever okay and the first time I went in for all these tests yeah these tests and I'm I mean he's filling them good lord I said is is that your largest is 36 very good so he's keeping records yeah at least someone is yeah brilliant is nothing like that no it sounds good so I've booked you this test they're ready for you in the waiting room yeah I'll see the results I'll write you a letter of everything I'll ask the hepatology team and both in about whether we look forward to hearing from them about that's okay okay that's great anything else at the bottom for any questions no I'm absolutely fine are you gonna be staying here in I'll be here for a year okay thank with training and then yeah and then I've got what 3 years left including this year you can tell them hey yeah like it nice nice nice evening hospital yeah I live I live in darthing but we can increase the abstinence to abstinence for over 2 years and we could add? Number 7 transplant assessment in birmingham 2024 no contraindication to transplantation however not listed for transplant currently go under that follow-up had the pleasure of meeting bowman in hepatology clinic today on behalf of doctor neil full stop the consultation was face to face full stop <\n\n> She is having her live care in 3 hospitals at the moment, she sees the dereffer team for regular urine etg monitoring and she's due to the birmingham team on the sixteenth for continued liver transplant assessment full stop 6 monthly full stop <\n\n> We were able to catch up about how things are going full stop I'm glad she just say she's feeling well full stop <\n\n> She's recently had her scleralactone stopped by the team in daraford due to a resolution in her ascites full stop paragraph there's some concern about a liver lesion but unfortunately I don't have any documentation from the birmingham or daraford teams about this I'll copy this letter to daraford who I'd be kind of grateful if she'd be able to send over have about this full stop I'd be more than happy to arrange for some imaging in mhmm to be if this was indicated full stop I know that she hasn't had any scans since with us since july 2024 in the way of hcc surveillance and so depending on the outcome from the team in darifen I'll either arrange an mri ultrasound full stop <\n\n> On examination in clinic today she has spina nevi jaundiced sclera but without evidence of shifting dullness full stop she has a very mild pedal edemaopathy full stop <\n\n> Of note she is driving full stop <\n\n> We agree that she's gonna have some blood tests today in order to assess her renal function and liver function on after cessation of spironolactone and also follow-up about her hcc surveillance I'll book you back in to see us in 6 months' time I'm more than happy to see her sooner we'll arrange any investigations here that may be required very much get the bloods