Boyd b o y d reed r e I d 218280 62 year old man past medical history asthma hypertension osteoarthritis medications list gabapentin 300 mg 3 times a day leu 4 beck inhaler 100 / 6 micrograms and cocodamol 30 x 500 tablets 1 or 2 to be taken 4 times a day as required on reviewing gp record note has been seeing them for leg ulcers and wound management of his right lower leg and ulcer as well as associated leg swelling no gastroenterology or hepatology letters but note was admitted in october 2025 leg swelling secondary to amlodipine aki premenal relates to recent thyroid illness and ramipril hypokalemic hyponatremia and macrocytic anemia investigations no acute intracranial findings left medial pterygoid plate unusual in absence of other findings and are therefore not felt to represent an acute injury an apparent cortical step in the left and medial pterygoid plate minimal surrounding edema an isolated fracture seems unlikely in the absence of other head injury could represent chronic injury or anatomical variation therefore less worrying creatinine 210 from baseline of 80 micromoles per liter potassium of 2.8 sodium of a 126 when was previously a 134 on the december 4 aki stage 2 liver function test alp 1 4 4 alt 39 albumin 27 bilirubin 45 and protein 58 ck 847 crp 3 urea 7.3 ast 1 0 7 full blood count hemoglobin of 95 when last checked in october 2025 was 1 1 8 with macrocytosis with mcv 1 1 9.7 platelets a 154 note decreasing rapidly since mid to late october raised rdw 17.4 neutrophils 6.16 and white blood cells 7.4 so both normal inr not tested and needs to be added on venous blood gas ph 7.33 electrolytes as previously described hypochloremia at 84 ionized calcium naught 0.93 glucose 3 lactate 9.6 really poly wound swab from the 12/11/2025 heavy growth of pseudomonas aeruginosa so add to the plan add on inr add to the plan repeat leg wound swab mr reid yeah mr reid yeah reid yeah hi I'm rob I'm 1 of the gastroenterology doctors at a medical restaurant coming this evening hi it's nice to meet you sorry to disturb you it's about half past 4 in the morning so sorry how are you yeah how do you feel at least oh well alright what. Did you tell me about that well he's got my hands and why are getting so high in it's what's my chair what's my chair where's the chair in the dining room right of your house yeah right do you feel like a chair in the dining room yes and how have you been feeling before that sweet time why is that it's been pretty fun in in what way have you been feeling crap just generally crap mhmm drained and washed out and not good is that why stress so psychologists say again yes gyologist say what sorry yes gyologist have a gastroenterology registrar oh yeah yeah yeah I'm 1 of the doctors to see around there and then so you've been feeling crap how long have been feeling crap for quite a long time quite a long time months not months weeks I suppose months yeah months feeling generally crap and then today over the last few days feeling worse and then today you fell off a chair yeah and did you lose consciousness when you fell off a chair I don't know good did you hit your head no believe so right and you've had a scan of your head which doesn't show anything worrying no I've just got a scan of it you have had a scan yeah yeah and it looks fine yeah because they're bleeding in your brain or anything like that no so that's yeah but your blood tests are quite deranged your salts in the blood are all up and down alright it needs sorting out in addition to that your liver function tests are are abnormal oh I they are and there can be lots of things that can irritate the liver later okay uh-huh 1 very common 1 is alcohol yeah do you drink alcohol yeah tell me about that well don't drink much how much is too much all my patients drink excessively so you can't surprise me with what you tell me yeah I'm always surprised tell me about it how much do you drink way too much do you drink every day yeah pretty much do you drink in the morning I don't know too but you do sometimes yeah you wake wake up in the morning and you drink yeah they help me work yeah I don't what do you do for a living I'm a loris driver fine of course I wouldn't expect you to drink on on your job but when you're not working you're drinking I can't you know yeah of course but when you're not working I can't drink when I'm working of course not but when you're not working you'd like to drink alcohol yeah and when you're not working how much do you drink in a day yeah I'm probably fucking too high I would how much might you drink in a day when you're drinking alcohol yeah I drink way too much could you quantify it at all really mhmm alright and there's cans yeah yeah those 500 mil cans yeah of lager beer cider both yeah both beer and cider man I don't have a can of cider more beer yeah is that export strength lager like 7% kind of stuff yeah yeah fine so 8 10 cans of lager is that reasonable no no 8 cans of lager a day yeah alright alright that's fine thanks for telling me that yeah I'll just you don't have be ashamed about it no 1 wants to drink that much and there are lots of reasons why people do mhmm and there's no judgment from me it's a an addiction and it's unfortunate that we are in this condition but we can do our best to get your get you feeling better and then also get you hooked up with the right people that have been doing that for you are you okay yeah I'm fine you fuck and how long have you been drinking that much for or boyd is it I should say your first 1 was boyd I'm fine just don't you know just oh yeah k so all your life yeah pretty much since you were 16 or earlier 16 mhmm and has your alcohol intake changed recently yes I'm slowing it down good because you felt so crap yeah understandable and I wanna carry on living of course I don't wanna die of course sir and so you work as a lorry driver still when's the last time you were driving 2 weeks ago I was just now in chicago so it's not some kind of work yeah yeah k so you last worked about 3 and a half weeks ago and then any other jobs other than noise riding oh for my sham mhmm uh-oh I'm sorry not lorry driving sorry it's alright I can take it it's a dream problem so it's not laurie trudden did you do I worked as a chef mate we use mostly we get loads and agents to work work mhmm and they pay well that's good and the driving work yeah mhmm do you feel like you want to drink now mhmm good if you want me to stick your hands out in front of you like this you're quite tremorless you've got a fine tremor and you can tuck your wrist back and leave it like that not with any of the problem you're able to do it with both hands keep your wrist like this with your wrist cock back keep them cock back keep them cock back can you lift your wrist up slightly that's lovely keep them like that keep them like that yeah keep them like that it's not as bad as can yeah well they're trying to travel a bit I know it's not a problem what's your problem good breaking out peripheral pulses that's good yeah I've never got a problem and stuff do you smoke no that's good have you ever smoked yeah I've been having how long have you smoked once smoked you got 12 units and how much how much do you sweat for over that time god you do it it's part of the 21 if you just try and keep your arms straight if you can then I'll keep going it's in a really awkward place I'm sorry oh how long did you smoke for about 20 years 20 years and how many would you say a day yeah about 20 pack a day yep mhmm 21 years okay and then you've got good for you so I was I don't need a good tummy it feels nice and soft and long and tender yeah it's got about 20 years ago I would have a scan of your liver in a minute as well with some machine oh yeah good nice regular pulses have a quick listen to your heart just 1 second I can't hear you because I'm listening to your heart sorry alright so there's a big guess for me if you're ready okay press it and again big breaths at the end 1 more time big breaths and I got this doctor and again alright let's find just here and here your knee and then if I look at your necks you've got this ulcer on your legs haven't you yeah where's which one's the ulcer is that on the right or the left right so I can see there's an ulcer on that right hand side very small clean looking ulcer yeah I'll pick that and a healed ulcer on the left hand side oh that is fine oh that's a shame you've got edema and swelling up through the hips bilaterally do you have diabetes or high blood pressure in your head you have high blood pressure don't you I don't think you have diabetes no I don't have diabetes know both of these can either need your arms to be straight unfortunately without them yeah it's not your fault it's just these pumps will keep beeping until they yeah cool fine so I'll come up with an ultrasound machine and if see you got any fluid in your tummy your your as I say your blood test show your liver isn't very happy your liver tests are abnormal you've developed a small amount of jaundice in the blood and is probably because of the alcohol that you drink now that you've stopped that alcohol because you're in hospital you'll see your liver get worse slightly but then get better over the next few days and weeks you need to stay off the alcohol in the long term it's very likely that you've given yourself liver disease because of this alcohol intake possibly liver cirrhosis so staying off alcohol is the most important thing you can do we know that people who stay off alcohol 70% of those people will be alive in 10 years' time whereas know that people who continue to drink we know that 70% of those people will be dead within 2 years stopping is the most important thing you can do for your health yeah I'm going to give you all good associated with the liver problems unfortunately you develop some damage to the kidneys because of being dehydrated and probably having an infection somewhere near the chest and that's caused these electrolyte problems in the blood yeah so you need lots of intravenous fluid in order to replace all of the salts in the blood that are low yeah you need a scan of your tummy I'll come and do a quick scan now but then we'll come down and do a formal scan after that we need treatment for alcohol withdrawal while you're in hospital which can be very dangerous so we need to manage that that's a lot you're very overloaded with fluid and so I'll get a jelly scan of your heart in order to assess that and echocardiogram and we'll also have an x-ray of your chest in order to look for an infection there yeah and I think that should be enough to be going on with does that sound alright yeah okay I'm giving up anyway yes well good I'm good well who do you live with at home 90 just yourself fine thank you do you feel like you have conversations for me no where do you want to go I'm done unfortunately alcohol withdrawal can make you feel very agitated like you want to run away and I'm sorry that you feel like that if you keep your arms straight we can give you the clinic and I'll give you some medicine to okay make you feel better and you empty out while you draw it alright let's get in the truck it's nice to meet you see you next time how do feeling sick yeah excuse me what's happening okay okay what's calling it gallbladder with tiny bitty stone in it nicely distended when's the last time you ate anything when's the last time you ate something when's the last time you ate anything I don't know never looks modular in outline your intake been food intake been like when you are at home are you eating anything much not that many any ascites it's just the articular part isn't it it's got quite shiny thank you I'm a little bit bit inflamed with what's going on we already knew that from your blood test yes good so and now everything sorted out I'm showing you the blood test correcting everything trying to you feeling better can you try and keep your arms down sorry for the itchy yeah because of alcohol withdrawal so you need some treatment if that will feel better okay okay see you in a minute yeah I'm gonna go ahead and open cake tomorrow say again can you open the cake tomorrow open the cakes you're not going anywhere my friend yeah I'm gonna use him okay okay I'll get the nurse to help you alright yeah yeah so then I'm going to the other 1 I think this 1 sorry can I squeeze past you're an av you're a good doctor thank you just scanning around the liver and the prostaglandins I'm getting off permission to talk this out it sounds like they've got a new presentation of cognitive disease problems with alcohol which cause my attention to complaints about hiv so yeah think we've jumped the vaccine so that is the penicillin reaction factor oh yeah and it can also so impression likely first presentation of decompensated alcohol related liver disease with significant metabolic derangement and acute kidney injury plan add magnesium phosphate calcium + - replace number next replace electrolytes iv number next ultrasound liver and kidneys number next input output monitoring number next catheterize number next alcohol withdrawal management number next pabronex number next noninvasive liver screening number next allerton ward number next alcohol cessation and alcohol care team number next add inr to bloods + or - give vitamin k