Angela beasley 4 '9 57 09/07 58 year old lady investigations england 80 '5 from 130 on the 07/26/2025 platelets 302 previously has been persistently normal mcv 100.8 previously macrocytic long standing h + 10.9 white cells are 11 cratin in 63 eosinase normal yeah lft is normal synthetic function normal amylase 102 crp 14 from previously 1 urea 14.1 ast 23 alcohol level undetectably low inr not sent venous blood gas ph 7.33 lactate 9.3 glucose 12.9 note presented july 2025 with a fall following intoxication unclear what happened I'm not leaving 1 now a ct demonstrating hematoma of the left aspect of the mandible I've seen it she's not leaving a at the inhealth mobile endoscopy unit follow-up aud proven previous reflux esophagitis struggle with intubation unable to complete without sedation due to see doctor summers in clinic in july 2024 but did not attend admission in june 2024 with a fall following alcohol excess self neglect anemia and multiple electrolyte abnormalities a low grade fever with an ogd demonstrated no blood or bleeding no varices but severe esophagitis with some nodularity plan for high dose ppi with the ogd came to the in house endoscopy unit but wasn't able to be performed and doesn't appear this was rebooked biopsies from both polyp in the small bowel and esophageal biopsies demonstrated nothing concerning hi missus sharma hi I'm rob hi I'm 1 of the gastroenterology registrars it's a pleasure to meet you how are you I'm 1 of the gastroenterology registrars I'm optometrist we specialize in gastroenterology how are you I've been better of course but I might be back not too bad I hear you've been having some black tarry stool is that right yeah tell me all about that in day mhmm just 2 days yeah mhmm and how about that cough how long have you had that for just noticed it now and what kind of stuff is coming out the bottom end is it as I describe it black and tarry is it sticky why are we doing that my that patient does wonder that and just a couple of days no longer than that no and any normal stool or is it all in black tarry stuff to the top no I think I've the stool last couple of days how many times a day are you going very very it could be every hour every hour really goodness poor thing alright and have you been feeling okay other than that in yourself no any chest pain shortness of breath pain passing water rashes anywhere pain in your chest or anything like that no and are you bringing anything up with this cough no nothing dry we're gonna have another look at you are you alright no really can't I don't see 7 is not 1 do you take any regular medicines nothing and tell me about your life you live in a house it looks like no they're ringing the house yeah you should by shop now to shop and these is this a formal package of care or are these friends formal formal carers 3 times a week yeah alright and tidying the house and things like that yeah yeah fine okay okay how about smoking do you smoke I do smoke tell me about that my chest x-ray is clear smoke like 5 rollies a day mhmm have you been doing that for a while not smoking right probably since I was 13 god poor thing hooked on it from a young age yeah and always about that much 5 rollies a day no okay and how about alcohol I understand that's a part of your life yeah and you still drink alcohol a big part yeah I'm sorry to hear that be incredibly difficult yeah can I take how much are you drinking at the moment can't look at the mirror thank you kira because I'm like yeah is she going it doesn't really it happens so quick yeah I'm just trying to in cup of tea in or with milk is that 7 yeah it's called and any more than that and how are you doing that what's the name again sorry I'm here I'm here see you've been in now past due a few times with the effects of alcohol whether you've pulled the puncture head or whether you've been being sick that's why I'm here did you fall this morning no have you hurt your head no alright did you hit your head my hand was good what made you fall then I don't know I'm sure when I was in the kitchen and I just go back and get you a plan you might collapse with this yeah fine okay my neighbor had heard me and he'd got keyed call me and came in he wouldn't help me up sugar this was today or last night no had a I bit of calmer isn't really want a couple of whack like woo wai walk yeah and you get redness on your palms floor that can also be for liver problems oh right okay let's just have a look at your upper chest you've got a few little notes inside of you by that we sometimes see when pressure's building up behind the liver I'll quickly listen to your chest if that's alright that's normal heart sounds you have to sit forward now and listen to your back any steroids or ibuprofen or anything like that no nothing like that that's fine just there if you're happy to do some big deep breaths for me okay he's now that's fine he's been less happy today so he's got some crepitations of his leg pains hang on oh you're painful next sorry was I seeing him he's smelling angry he came in with hip pain they thought he had a sore throat and he was like yeah need a bit of tlc don't you oh but you definitely give you a bit of tlc is that alright we'd like to look after you we'd like to look after you up on our liver ward if that's okay no we'd love that up on allerton think we've been up there yeah you'd grow yeah maybe back in june the nurses will be really would love to look after you and make you feel better and we'd love to help you from a liver perspective get better you need some treatment for alcohol withdrawal because you're likely to withdraw in hospital yeah you need some medicine to try and stop this bleeding and then you probably need have an endoscopy tomorrow to have a look down by the try and see what's bleeding and fix it in the meantime I'll give you a drip of some antacid medicine to try and stop any bleeding okay I'll get an x-ray of your chest for example your urine slip for infection your blood tests look like you've got an infection and sometimes that can make everything a bit worse as well so I'll cover you with some strong antibiotics for a chest infection okay alright your blood pressure is good 150 and 79 the heart's gonna pass to a 123 that's and that could be because of your body fighting infection or responding to the bleeding that you're having alright is there anything else I can get you while you're here I feel better very thirsty think I have it alright thank you very very I've had her before her who she's with concern because the carer are phoned to say that has she had carers sometimes a week since last september I think of me what they are doing so was all the pain she was beating by her heart thank you she's just I'm horrible at the back of my day yeah and milk and that's all all the white mushrooms no no is that what it is have you only had 1 0 I've never seen I think I think that was a thing like it should show she shows that I'm not really with it no she can't get it I know sounds like a good thing so oh no no no of thing do you look at her feet I'm not oh no no mean you do it shit brown I didn't I've got I I kinda had a hard 1 coming the camera I did as well of course but yeah she said hospital likes to talk about resuscitation about what you'd want if you were to get worse in hospital from my perspective you're very you're quite bawley at the moment but we should do everything we can you're obviously gone you know of course alright let's get it later maybe so I do everything for you my colleagues will look at why you're having feel that people with bad livers who continue to drink carry on having a meal too may not do very well in intensive care we should have those discussions if we need to at the moment we don't need to have those we need to alright okay hello okay shall I get you something for your nails because you've got a bit of a fungal nail infection would you like me to get you something for that while you're here not right now that's fine yeah do you remember what happened this morning so impression upper gi bleed in the context of ongoing alcohol use no evidence of portal hypertension at time of previous endoscopy however variceal bleed remains a possibility most likely chest infection given given wet sounding cough and right basal crepitations but to investigate and exclude bacterial peritonitis as a cause of raised inflammatory markers and to exclude alternative infections poorly kept significant concerns about self neglect and and the role of the care team at home over and above supplying her with alcohol and so will need thorough social sort out before going home plan is allerton ward tech for full escalation currently add on inr + or - vitamin k ultrasound liver ppi to cover for peptic ulceration given there may be a delay to endoscopy until tomorrow no vt prophylaxis given bleeding could have physical vt prophylaxis with teds septic screening chest x-ray msu tazosin 4.5 g tds iv consider treatment for fungal nail infection once patient improved if hemodynamic compromise with bleeding consider urgent endoscopy and discuss with an endoscopist small and a bit of a marginal outline as you might expect hello let's see yeah you hear a bit I can't hear the part can you see let me do that let see I and this 1 that oh yeah another ct scan and that will be taken for her daughter to develop it okay and just go ahead and ask her to that