You michael my name is I'm 1 of the shl calling from hi I just want to discuss a patient with you if that's okay yeah of course patient's name is miss eleanor rod hospital number is 515 okay 408408 is a 77 years old lady who was admitted 5 days ago with aki 3 generalized fatigue the thing is I've noticed that her hp has been dropping since admission on admission it was 1 22 and today it was 74 mhmm so I did pr her and then she has melina okay on examination the other thing is that she also got deranged liver function test since admission with her arb of 4 52 today the peak was around 4 37 alt 87 yeah very high isn't it inr I think it was to 1.2 it was slightly improving initially it was 1.6 she had ultrasound abdomen as well which was reported as normal liver appearance and gallbladder is normal bilirubin is all all normal mhmm and she has this ongoing melena the only thing that she's on is the enoxaparin for the prophylaxis but I've held it today okay she's been complaining of some chest pain today so I'm thinking could possibly second unit I'm just wondering if she's going to do anything else she got liver screening bloods done as well good they are still pending with autoimmune liver profile still pending I think hepatitis c is negative mhmm I think hepatitis c is negative as well rrct1 level and hepatitis as well giving I mean how long she been in hospital for well it looks like a while yeah it's been a while yes so her paracetamol level probably if she overdosed before she came in isn't gonna be helpful unless you think there may be a occult she may have taken a paracetamol overdose while she's in with us is that a possibility no and we're not overdosing her ourselves with with 4 times a day dosing when she's a tiny lady she's not a tiny lady she's not a she weighs around 60 76 kg so she's average average weight that's fine and the last time we got an inr was the nineteenth is that right or yeah and the last inr was and it was fine then wasn't it it's a little bit weird isn't it why what's what's causing her liver function to be solved is she on antibiotics she is on for possible biliary sepsis fine okay that's oh so you think so you've started her on that based on these blood tests is that what you're saying she was she was started on on admission I think they just assumed that because of the liver derangement and the raised crp of 4 1 she was treated at biliary sepsis after discussion with micro okay and she was started on clotrimox the the thing is her blood culture also was then deposited for e coli okay yeah so gram negative she was febrile at 1. And then and then she's becoming more anemic possibly bleeding fine that's easy to fix isn't it she should have an endoscopy if she's a good candidate for that and you're gonna give her a unit of blood which sounds good and then in terms of the liver function tests it's difficult to piece together what's causing this do we have a ggt it doesn't look like we sent a ggt if you send 1 with your next blood test that'll be really helpful just so we can work out whether it's coming from the ducts or not but since records began her liver function tests have been off just trying to get to the old system see what cybilab says and alcohol no do you mean I don't think it's been sent for blood alcohol no I don't I don't need a blood alcohol because it's not gonna be unless you drunk in the last few hours it's not gonna come back is it positive does she drink is there anything in the social history no fine yeah fine history fine that's helpful to know let's just find so her liver function tests were normal back in 2023 then there was a spike in alt and then now it got better does she have pain she does have epigastric pain epigastric pain I forgot to mention no that's fine is that why she's in hospital no I think her main concern was that she was feeling generally fatigue mhmm yeah fatigue was her main issue generally unwell flu like symptoms and then she was found to have aki 3 on admission that's why she was staying inpatient so I think we were mainly focusing on the aki 3 and we're doing the renal screening and everything she got the aki has got better that's good yeah but the echoes is improving and she was jaundiced at 1. Wasn't she it certainly seems like we've got something better I guess if she's got pain we haven't found a cause for pain have we we've we've not really I don't know I'm when I read this ultrasound report it gives me the feeling that the person doing it didn't have very good pictures technically scan due to high subcostal position the liver where visible appears normal along the aorta the intra intra the spleen I just worry that they haven't really done an excellent test with that and I think that the other option would be doing a ct or an mr of of her of her abdomen and pelvis I don't really mind which do you what's your clinical question where do you think the e coli is coming from her biliary tree I'm thinking could this possibly possibly be like a gastritis or something I'm not sure 1 more question is that my question is will she need an endoscopy and do you want me to start on the ppi yeah so the with the bleeding she need she should have an upper gi endoscopy shouldn't she and we should be able to do that tomorrow so I wouldn't start her on ppi I'd just wait unless she's not hemodynamically unstable is she she is stable but she's stable that's fine so don't start her on ppi just hold her on prophylactic and oxaparin and give her vena pumps or teds or whatever you wanna do instead and then book her for an ogd tomorrow the so the e coli is coming from her urine isn't it so she had got a positive urine culture yeah she also got positive urine culture yeah so the e coli is not coming from her bar ducts it must be coming from her urine because we've cultured it from there it's all a bit weird and I think probably some cross sectional imaging would be helpful particularly in the context of pain if someone's got tummy pain and we haven't really found out why and they've got these abnormal lefties I don't think it's an unreasonable thing to do to do a ct abdomen and pelvis it's very sensitive for force for duct dilatation so if we find if we see dilated ducts on the scan then we can be quite confident that they're there and it'll also look for alternative causes of infection and deranged lfts over or above just doing an mrcp so I think that's what I would do with that if she has pain right so I will refer for the ogd for tomorrow I'll hold off ppi I'll request the ct abdomen and then send out blood for tomorrow including ggt ggt that'd be really helpful and an inr tomorrow would be good as well wouldn't it yeah I'll send off for inr brilliant that sounds good yeah okay you thank very much so much thank you talk soon bye bye and that was eleanor road r a u d 515408