Lisa rogers 414396 58 year old lady this 1 here looks like a dog surgery physiotherapy so investigations today pt mixing studies pt 51.1 prothrombin time 23 with inr 1.6 and class fibrinogen 1.7 aptr 1.29 full blood count awaited amylase awaited venous blood gas lactate 4.8 with hemoglobin at 74 from 97 on december 21 urea 2.2 renal function normal bilirubin 23 with albumin 33 and alt 56 crp 3 ast 124 troponin t 7 take it back I'll actually ignore those last ones because they are from december stop after the venous blood gas right osteoarthritis of the hip july 2025 referred for hip replacement type 2 diabetes mellitus 20 22 asthma migraine hypertension medications list benpedoic acid 180 mg once per day metformin modified release 500 mg at breakfast and 500 mg at evening meal candesartan 16 mg twice per day sertraline 100 mg once a day amlodipine 10 mg once per day hello is it lisa yeah hi I'm rob I'm 1 of the medical registrars I'm 1 of the gastroenterology doctors pleasure to meet you how are you I'm I'm sorry to hear you've been vomiting some stuff up what have you been bringing up I'm seeing it in the blood it's red bright red it's dark blue like all night after sleep yeah definitely red definitely red yeah and 1 time couple of times about 4 times but in succession mhmm there wasn't a gap it was just constant coming out mhmm 2 litre container of ice cream container mhmm each time or in total sorry each time or in total not in total yeah what a funny thing to have high air were you eating ice cream in bed just before no quite often does that sound lovely no I you seem that yeah first thing no first thing in the morning I can be a bit flummy so I like to pop around I see because with my mobility at the moment I can't get to mhmm yeah that's why keep falling over yeah so I try to keep and it basically it comes in for numerous mhmm plans because if I can't get to the mhmm or dad's in the loo or whatever hanging then hanging a port handy is quite handy yeah so you brought up all of that stuff yeah that was about 03:00 in the morning last night is that right well this morning yeah this morning I'm glad that I had brought up a tiny little bit of I got a seat nurse normal stuff that I bring up in the morning mhmm it's normal yeah you're on bloody stomach yes mhmm but it's fine it's just normal for me anyway yeah and anything at the back end nothing nothing unusual no jet black tarry stools no nothing when did you last go for it smaller smaller I mean it's bright on the front yeah yeah a bit lighter I've been having it was me meggy was quite right the last week or so so it's reasonable I've been slightly constipated only for like 24 hours and then it's clear that not present whether that's connected or not I don't know but that's not clacky that it's just yeah yeah storage they get bundled up you know yeah probably because I'm not eating enough so I will just come back because I feel sick all the time why did you feel sick all the time I think it's the medication someone mhmm someone my blood's swelling in the morning so I'm on metformin certainly yeah I read about your blood study your medication yeah yeah forgot about the sercetrily that's fine just double and I just think the combination of all of it makes you feel nauseated yeah okay I've tried spreading it out during the day I just feel sick all day yeah so mhmm it's a bit of a circle really yeah course and I'm just getting it down very often I don't know how it works like whatever liquid I take and take them down comes back up the tablets themselves don't I see no I don't I never do 10 things easily mhmm what led to you not coming to see us last night where you wanted the blood what did you were you worried last night or you just thought I'll just go back to sleep and everything will be okay in the morning like bit of both really with being a curved dad I can't it's hard for bits yes ma'am so I couldn't leave him I thought right I've stopped now if I'd carried on I'd probably have had to run a good night yes last time I fell on the couch I think he had to come in with me mhmm which I didn't really wanna do today of course so you live with your dad at home yeah I'm I'm 24 7 it's a good adventure oh yeah purpose so it's it's yeah it's not a good life at the moment do you live in a house or a flat in a bunk bed yeah dean brixer yeah come on I've got some sleep bug area things are upstairs okay right and let's move to bug area have you diagnosed okay is this my leg right it's it's easy to go but doesn't matter an impression quickly yeah I got up to the toilet this morning and then I just it's it's always in the night I suppose I'm half awake half asleep listening out for dad mhmm because he he does he hasn't wandered at the moment I've got an assistant stuck at home that will alert me if he moves okay that's why I don't sleep properly mhmm because you're thinking about him I'm comes to him and that to him so yeah I've got we have a guide coming in the morning day 1 coming in in the afternoon and then I came to watch the morning she's great and a friend of mine's just gone sarcophoric what do you do in front of him I'm 24 7 care of her fine my friend's just gone sarcophoric I was gonna say no she's doing everything so she's with him at the moment mhmm it's got rapid response from 10 till 7 okay that's good fine we've got a slight between 7 and 10 in the morning but his wishes a little bit by that alright he's under a promise to behave himself oh that's good not fall over that's alright then isn't it yeah exactly because we do not move that about bed mhmm good and kiss is worried about me but he's trying to be independent yeah and I'm like don't mhmm yeah you're not well enough and she's put it's more like an iron at the moment mhmm we get it yeah and when everything's going on with your hip and breathing it down and stuff I'm I understand alcohol is a part of your life will you tell me a bit about that she's actually yeah yeah are you anxious till the evening because there's more just see you okay don't drink as much as I used to you were worried don't drink until the evening mhmm you had that sleep relaxes about to out to sleep as opposed to get you know I never was never gonna go up in the morning and start drinking it's probably habit because I don't have to have it yeah okay so you don't drink in the morning no no but you will drink every evening not every evening but every evening most people it all base basically it's depending on what's going on yeah of course and what might you drink not that much more can they be able to put around mhmm or the other way around mhmm you know it's because I'm so unstable at the moment and it's just take the ads off it's not like I'm staying the corner I think you know volume on the floor and you said you used to drink more previously how much do you drink in bed do you know my voice I'm not having a book a book a day am I night people how long did you do that for years decades potentially yes more likely even time passes so quick it does yeah scarily is there any chance of using a loop a loop in a bit on it for a wee while maybe yeah a wee yeah and we can bring a loop to you is that alright yeah yeah you're close you're desperate yeah I'm getting there yeah fine could this lovely lady go for a wee is that what you're saying of course thank you do you wanna know how you'll manage it maybe you've come over peter perhaps oh yeah maybe you're not thank you okay I'll you can I pop again yeah sorry I wanna get this out I've got a nice regular pulses you wear a ring on this finger normally yeah right it's a copper stain it's been much longer a bit of foam roller please I've got that in do you feel a bit sweaty no you're anxious and sweaty yeah I'm I'm always sweaty when you're a sweaty pulse you know like they're drooling from alcohol a little bit but that can happen sometimes it can make you feel really crap I don't feel crap I feel like my brother the main bit tremulous and sweaty and your jaw's trembling a little bit and I sometimes see this with people and obviously when you vomit you can't drink a lot that can really set things up yeah exactly yeah that's a good part of crap anyways is not not been part of it it's when I get up just a little bit bit yeah yes it's fine when when you get up when when I go to get up mhmm I've got at home I've got a walker mhmm I've only had the green for about a week mhmm any hospital or I've got a walker do that yeah you walk in a walker all the time yes you're a old walker yes 3 no 4 4 little outside the house much no no you don't get out because of your knee because of your hip at the time yeah well I've got quite a knee on that side and nothing down this side mhmm so I can't drive a car of course I bought a car she's got a car haven't got 1 haven't it even if I put my wheels to the car or get someone to put my when I get out the other end I still can't walk so I need a car I can sit on then it's all got worse and rough I can't get down the stairs now mhmm I'll get them if you're desperate for any of our lucky nurse I'll be up there for a minute and we come back and talk that okay yeah we'll draw 1 of this out for you don't worry can I take that 1 take I'll take that 1 I'll that take I'll that's I'll 98% pulse rate 109 blood pressure 149 over 94 respiratory rate 18 the difference between the old kids it's you not your gastroenterologist yeah that's great that is amazing my my first year your jaws wouldn't work no no I know it's been a good weekend of it yesterday yeah just kidding you can do it exactly never listen to that bye bye so the plan is so impression is first presentation of decompensated alcohol related liver disease with some clinical evidence of jaundice but biochemical evidence awaited and upper gi bleeding with clinical evidence of portal hypertension with spidanevi on the chest and palmar erythema plan allerton ward iv fluid alcohol care with pembronex and chlordiazepoxide chest x-ray msu blood cultures to complete septic screening a weight blood test including inflammatory markers and liver function tests vitamin k 10 mg iv for once a day for 3 days ultrasound liver formal if further episode of hematemesis for 2 mg of talepressin and discussion with on call endoscopist ogd referral to be undertaken tomorrow given evidence of upper gi bleeding with potential varices ppi given possible underlying esophagitis as a cause for bleeding tap full escalation as first presentation monitor hp overnight and if dropping consider transfusion so she's had 1 unit she's having 1 unit transfused for a hemoglobin of 74 add to the plan iv antibiotics with tazosin to cover for variceal bleeding can I look at your tummy yes yes any pain for some water any cold or anything like that cold chest so your liver's a bit shiny echogenic that can happen when fat gets into the liver and that can happen when you drink alcohol as you're doing in the past you've got a gallbladder there with a tiny little stone in it but I doubt very much that's causing any problems for you your neck is quite big which is a good sign okay good to have nice big and opacity for it to heal sorry if that's a head no sorry sorry no it's gonna be a well well that was a head it's not any normal it's the whole now yeah know yeah I've read about it and the physiotherapist sounds really bad yeah it's really bad 1 knee and other really and thanks yeah there's no fluid in your time which looks good let's just stop off for a minute so what can you do that time for 7 I mean when you some stuff I mean I can make you sick well you you can make you like sleepy don't you I don't think that's the right thing to do I think we're on this but we're making very sleepy okay alright maybe you you won't I don't think you need to do so we have only introducer right now and you've also got sprays on the back of your brain back no it's cool so we can do that so have a have a listen to your heart yeah cool what do you have don't that's fine I'm glad this is no worries the patient when you're doing it what do get well I'm gonna scan your liver I'll get the to properly scan your liver I want someone who's very good at that it's not just does it on a has a moonlighting like we do and they can have a look at that area as well make sure there's something's reasonably there so yep we haven't got all of your blood tests yet well first blood tests show your blood counts drops in keeping with your bleeding and having a vomit starts in blood the 1 of the blood tests shows that the blood is quite thin and more prone to bleeding and that going with what you tell me with the drinking alcohol makes me worry that your liver isn't very happy sometimes pressure can build up behind the liver when it's not very happy and that can cause the rashes really to make it very happy really you okay alright I need to help you then yeah it could be your cat I had a very cuddly maine coon who used to knead I see that and and the redness on your palms makes me concerned about pressure building up behind the liver and that can cause a bleeding that you're having from distended blood vessels over the gullet yeah and it can also cause a pattern on the blood test that we see so I suggest giving you a good few things to try and sort things out so you need some strong antibiotics because when you're bleeding you have lots of blood going through your gut and that can increase the risk of getting an infection in the gut so I'll give that you need some blood thickening medicines some vitamin k to try and replace any dietary deficiencies that you've got I'll get you some of those need some nutritional supplements to try and build you up get your protein intake up and we can sort that while you're at work I'll give you a drip of some fluid to go alongside that we'll give you another 1 I'll give you a bit of protein we'll get a tracing of your heart if you've not had 1 of those already yeah and this 1 can come in somewhere good I'll have an elective I'm still hooked up if you vomit any more blood we'll give you a medicine to squeeze the blood vessels in the gullet a little bit and like I said I'll get a scan of your heart scan of your liver I should say and we'll give you some good alcohol care to make sure you don't withdraw from alcohol and give you some intravenous vitamins because when you've been drinking alcohol sometimes the absorption of vitamins can be reduced am I alright no I think it's I don't know how to all of your blood tests yet but I worry looking at you looking at your blood tests and looking at everything else you're damaged your liver quite significantly know worry that this is a sign of liver cirrhosis there's no reason I can't tell you for certain without the formal ultrasound scan but looking at your liver on that scan I'm worried that you may have a quality of a disease there's no reason why you can't live a completely normal life but for you a completely normal life involves no alcohol we know that people who have liver disease because of alcohol and continue to drink 50% of those people will be dead within 2 years k most people who stop drinking alcohol 80% of those people will be alive in 10 minutes there's a clear difference that you can make and we can do we can support you in hospital to make that change big change because a big habitual psychological and physical thing while you're in hospital we'll get over the physical thing and they'll give us time to work on the psychological and habitual aspects we've got some great support services stanley okay okay we'll have some it's been to call you're gonna be in for a good few days I think okay yeah you need to have a camera test to look down to see what's bleeding and fix it okay we need to have some good supportive care for that time while you're in us I would bargain grappling and this would be up on our living ward full term but I'll take you up in the coffee he might as well be looking after you'd be able to right I know it's a lot of information and it's very large I specialize in this thing so that's it so very long yeah alright okay yeah alright we'll we'll see you on our lovely ward in a few days time let's just get up there hey I'm gonna see you about you'll come from here to acute medical unit for a day and then you'll come up to our ward you might go straight there if we get a bed for you would be great but we'll keep looking after you don't we I'm really worried about the test right now no you want someone to look after who'd make me safe and you can't look after him in the state you are at I'm not done exactly I'm done this is life threatening to me all threatening okay well you did just say send her on the way because it just sounds like you thought that she said hello no it's not you no I didn't I wanted to know that you're on here if you need that that's fine so she'll see how you clean how you clean again and I'm okay and okay fine and you'd need to get the case so my job now is to see is to say 10 minutes I will teach you you're alright but what else a few hours of good at age what else are you doing that's fine so my husband is gonna say you know I'll see how she gets sent me to me a caretaker think she went she's some access great yeah she's been fine good news tell them what I am no but I like I like to see her she's doing well for you it looks like you're doing good job in there well I'll try and listen to things you're right well I'll she needs another blood gas and needs a second glucose in clinic lovely I see seizures