Transcription - 20251119T 21-25.mp3

Andrew mathias 1264881 66 year old man investigations alp 3 185 alt 42 bilirubin 64 hello 19 gtt 2 0 9 1 folate normal a 132 creatinine 97 at baseline crp 33 ast 51 tsh normal transferrin saturation normal autoimmune liver profile weighted full blood count normal medications list avandavaxin 37.5 mg modified release once per day rivaroxaban 20 mg once a day atorvastatin 80 mg once a day ramipril 2.5 mg once a day tamsulosin 400 micrograms monfiber release once a day vitamin b costrong 2 3 times a day bisoprolol 5 mg once in the morning metazepine 45 mg once at night omeprazole 20 mg 1 to be taken each day past medical history carotid artery stenosis on the right 20 21 leading to tia in 2021 carotid endarterectomy august 2021 subsequently started on clopidogrel and well subsequently started on rivaroxaban and previously on clopidogrel and then stopped intentional drug overdose in 2020 alcohol withdrawal in 2016 atrial fibrillation in 2014 esophagitis 2009 inguinal hernia repair on the right in 2010

Issues:
1. Abnormal liver function tests
- ALP 185 (elevated)
- ALT 42
- AST 51
- Bilirubin 64 (elevated)
- CRP 33 (elevated)

2. Complex past medical history requiring medication review
- Multiple cardiovascular medications
- History of alcohol withdrawal (2016)
- Previous intentional drug overdose (2020)

Background:
66-year-old gentleman with significant past medical history including carotid artery stenosis with TIA in 2021, treated with carotid endarterectomy in August 2021. Initially started on clopidogrel, subsequently changed to rivaroxaban. History of alcohol withdrawal in 2016 and intentional drug overdose in 2020. Other significant medical history includes atrial fibrillation (2014), oesophagitis (2009), and right inguinal hernia repair (2010).

Current medications:
- Venlafaxine 37.5mg MR OD
- Rivaroxaban 20mg OD
- Atorvastatin 80mg OD
- Ramipril 2.5mg OD
- Tamsulosin 400mcg MR OD
- Vitamin B Co-Strong BD
- Bisoprolol 5mg OM
- Mirtazapine 45mg ON
- Omeprazole 20mg OD

Investigations:
Liver function tests: ALP 185, ALT 42, AST 51, Bilirubin 64
Other bloods: GGT 209, Folate normal, Vitamin B12 132, Creatinine 97 (baseline), CRP 33, TSH normal, Transferrin saturation normal
Autoimmune liver profile: Awaited
Full blood count: Normal

Impression:
Abnormal liver function tests with elevated ALP and bilirubin, likely cholestatic pattern. Differential diagnosis includes drug-induced liver injury, biliary obstruction, or chronic liver disease. History of alcohol withdrawal may be relevant.

Plan:
1. Review autoimmune liver profile results when available
2. Consider hepatic ultrasound to assess biliary tree
3. Review current medications for hepatotoxic potential
4. Monitor liver function tests in 2-4 weeks
5. Consider hepatology referral if no improvement or further deterioration

Summary

Investigations

Plans