So next patient is cynthia abdi foxtrot 1 43923 70 year old lady presenting complaint to hematemesis investigations creatinine 44 baseline 35 electrolytes normal alp 141 inr 1 bilirubin 10 full blood count reveals neutrophilia 8.6 macroscitosis 110 note recent noninvasive liver screen ana positive hepatitis b c negative hiv negative note recent ultrasound liver april 2025 diffusely hyperechoic and attenuating liver in keeping with hepatic steatosis no gross liver lesions normal liver outline normal normal hepatopetal flow in the portal vein thin water gallbladder no ascites past medical conditions alcohol excess restless leg syndrome hypothyroidism gastric ulcer 2004 left hip osteoarthritis depression alcohol use disorder instead of alcohol excess is nice way of putting it hypertension was noted to be drinking 260 units of alcohol per week back in april 2025 when she was admitted with drowsiness and managed for alcohol withdrawal medications thiamine 100 mg once a day levothyroxine 100 micrograms once a day ropinirole 250 micrograms or 500 micrograms at night as required citalopram 40 mg once a day allergic history penicillin co amoxiclav itching and lip swelling that's the investigations blood gases on admission ph 7.13 on a venous sample with lactate 11.1 and on subsequent testing an hour after ph 7.15 with lactate 11 still feeling sick yeah you've been that's what most brought you in wasn't it lots of vomiting at home how long have you been being sick for only since this morning it all started this morning yeah right any tummy pain with it now yes after all being sick but it didn't start with tummy pain no no it started with vomiting yes and I understand you brought up some blood is that right yes tell me about that tell me more you how much blood came out I don't know that's okay yeah you came up mixed in with the vomit yeah yeah was it well I don't know if there was vomit in it just all blood bright red not quite red okay like pink blood granule I thought so but I didn't really oh fine it wasn't fresh red blood no no fine just brown stuff just vomit yes fine yeah yeah brownie sort of thing yeah fine yeah no one's allowed to vomit anywhere near a hospital without someone calling it coffee ground vomiting do you know I mean the moment you say vomiting everyone says coffee ground vomiting but probably just vomit vomiting isn't it no doesn't really touch it doesn't make me feel sick I'm happy you don't have coffee gradually is that right no but but you're vomiting a lot and you're still vomiting and we need to fix that okay well you sorry you're on top of it yeah sort of heaving and not much mhmm but stuff's still coming up yeah okay so let's get you some good strong anti sickness medicine don't know you've been that would would be really good because along with it is the feeling over or being sick that's what you're I think you've been quite sweet as well yeah but as opposed to she's struggling with her energy of course yeah and what do you know about the tests you've done since you've been in hospital and what we found things like that nothing nothing fine perfect you have to say I said that I said I recognized her from before yeah she reached us oh really fine yeah I recognized her and she said I said oh what's wrong with you then she goes I don't know I wish they told me oh sorry fine didn't know your blood tests show that your blood's quite acidic which can make you feel very sick and vomit and there's a raised level of lactate in the blood which is a type of acid that your body produces when it's not very heavy when the cells are not happy for whatever acid is oh it can happen very commonly in people that drink a lot of alcohol oh and they have red blue letters they say you were drinking alcohol in the past is that still a thing for you yeah but how much do you drink well I haven't had any today that's good 5 years believe it and how about yesterday I was thinking about bringing it in with me but I just decided that would be a bad idea fair enough we probably haven't yeah I I wish they normally have but luta alright with vodka yeah mhmm and do you mix it with anything yes sometimes I do sometimes I'm thirsty rather than just luta yeah yeah what do you mix it with lemonade lemonade okay and how much lemonade do you get through do you mix it a lot quite a bit yeah do you have maybe but I've got of 2 3 maybe a liter for a liter a liter for a liter 1 to 1 yeah okay alright so about 2 alright fair enough yeah and how long have you been doing that for a little while now yeah can see your letters because I came in before because I fell over like in april I think was it or may was it so I've been relatively recently think last few months I came to hepatology which is my specialty right but I did we didn't meet at that time oh okay but yeah I came to our ward oh okay blood liver liver mhmm oh okay yeah yeah avon ward downstairs it's very bright and new oh yes flowers on the ceiling yes nice exactly yes yes yes very nice ward it is very nice yeah we like it yeah not as nice as you though I tell no I do hate say that just have to say that have say that that say I'm not sure because it's a self like it's a 1 time I came somewhere in southland yeah yeah I'm still in who you are but you're taking your blood sugar sorry why don't you carry on then it's a good plan no it's too I think you're gonna get it in with blue then just bled everywhere really shut up and go away in the whole bit so no no that's fine you can tell me that and I will fine I won't take it back is at my flat this this morning mhmm they're talking too much alright alright and this is people that came to visit you in your flat no they come and do I need to go on the stations yeah I'm sure you know do you around the house yeah fine is that so that do they come every day yeah usually just 1 comes mhmm mhmm yes they do come every day they come every day to help you around the house yeah they clean and things like that and do they help you get dressed and things like that or no they don't no I don't want that to be yeah the case yeah and my neighbor is very good oh great shopping washing oh that's lovely yeah is that how you get the vodka yeah but what she says no there's not because I can't walk my head because yeah you've got a nasty arthritis in there in this sense yes yeah sorry about that no france you don't walk much so the and they've done all the shopping for you yeah and the alcohol yeah go on sorry have the operation but guys even think about it because of the bottle mhmm it's horrid isn't it the effect it has on all parts of your life yeah it's so tough isn't it yeah you it's rubbish you're 1 of these addicted personality people do you smoke as well yeah yeah mhmm so hard isn't it when you're that kind of person it's really tough to when you get in those habits to break the mood I'm a bit confused yeah I know what you mean I think I am too gonna take this person do it every day no I don't know yet sometimes usually yeah yeah I just got taken on water oh 0 so that's the thing yeah but how long have you smoked before oh we used to go for cigarettes behind the bike sheds yeah yeah when you were 16 kind of thing or earlier 13 13 you're not sparing yeah and how old are now great I was gonna take this off a because I've been trying get yeah right so you've been smoking for about about 55 years would you say a bit more than that yeah and over that time would you say most of the time you take a pack a day or more I think well it's not reddy's now because the cigarettes are too expensive and they are very expensive and it's I don't know apart from me couches or bathtubs ah well I don't really pay much attention because I don't buy them how often does your neighbor get you shopping well she picks something up maybe every day right and but maybe once a week she'll buy you some tobacco more than that yeah saw you maybe once a week that would be kind of not a pack a day kind of stuff would be a pack a day a pack a week yeah a pack of a pack of rolled up tobacco would usually make you about 10 to 20 cigarettes a day kind of thing does that make sense yeah sorry sorry I'm sorry oh that doesn't sorry it I don't like that oh not many people do that's not nice at all sorry we're not nice in this I know so tonight yeah if it hurts I think but it doesn't hurt now has anybody ever been the yeah yeah it really hurts to get it in and but it'll be good to get it sorted out we're just trying to get another cannula for more extra it whatever it is that's better for me but we just we need to get some more blood tests from you because your blood tests are a black and blue in a minute that's alright alright you can do it well I'm already black but not the black and pink 1 thank you janitor that's brilliant amazing was tell me show that I'm telling about you you live in a flat yes have you did you work in the recent past obviously with your hip it's difficult but what what did you last do for a minute no because I've been in for about 20 years and you were in london before you got a london accent yeah yeah north east london south south alright okay yeah whereabouts in south london crystal palace okay lovely alright and what made you leave crystal palace for plummer alpha okay they sent me to the rehab fine you came for rehab and never left yeah fine great that's nice because it yeah it's it's I think it's nicer than london me too I hope you're up in twickenham not really london oh no yeah yeah yeah so you need know is quite posh it's quite nice yeah it's nice but yeah I I miss the sea too much think they just come down here oh too busy for me yeah yeah find the same thing if you went back you got a handle there and no still haven't done that no for 1 thing when I went back to visit my granddaughter mhmm we went out walking down and all that and I said oh my in my head I said squeeze my hand and watch the husband and he says oh can I see this thing that's beautiful yeah I can't can give me more of a squeeze than that that's oh ow ow ow ow I don't like it at all you know honey I hate it when people sticking things can I not you did answer my question can I drink for whatever it is you can drink but we want some more blood tests yeah unless you're gonna vomit unless you're gonna vomit off more blood between wanna go there be okay there but yeah the bleed might be alright there but it's yeah I know I was thinking about I believe there but you're unlikely to be perfect I'm just really struggling to find yeah know you can they are small and she's very dehydrated yeah she's just I'll get you a some water I'll have the pink yeah I think we're loading a balloon in last yeah okay alright I I can't do it yeah no I wasn't sure no it's fine yeah I know that reflux is like 3 20 so they're not coming out alright yeah I know I mean I didn't actually get any of these you give before right had success but just didn't feel good yeah I think it moved yeah so it's okay was all yeah I'll just go are you off to fine vessel here you don't hate being beaten but which you don't have to be you're oddly with a hink I think yeah I don't know can I just borrow a stethoscope with you not gonna let him in no I know no but it's that sounds awful warmed her up for me you know yeah but are you ready at me didn't help brother couldn't say what I'm getting probably just gonna be ready so do we need to take this to packages I I think I don't think it'll be I don't think but I think it will be I would get home from my doctor this thing will come up with me is it ow it was I'm not even what it was yeah this is what happened with me and it's plain yeah I'll turn that away in a just can I get some tons of it doctor wickia there's it's they said they're taking out of the bag thank you we go I wish I tried to get some yeah to kiss me didn't really I don't know if you're well it's alright I think I'm just gonna sample a hematoma on-site someone showed me that trick the other day it get something but I don't think we'll leave anything I can run with it that'd be great thank you I'll take a bit and then I don't even have to do it's window hasn't it yeah it might stay will it no it's not but you can just use it as a it's a bit of a vicious circle usually have do it it's not working is it not working no oh see I'll let in that case help persevere it's a bit of practice feel I thought after you've analyzed it you might chuck some in the in the gold bottle yeah of course good what do you want ty some water yeah yeah what you're try and get it from there to go into the yeah once we've analyzed it yeah you're welcome just track it in the in the gold it should be an option isn't it we just want a gold is that right yeah yeah yeah so after you stick it to the analyzer pop the top off and squirt it in and put the top back on it's literally colour really yeah I don't really change your life you can't do it the other way around though once it's been in the tube you can't handle that name again cynthia abbvie thank you for your time alright good and do you feel that you're coming off these at the moment cynthia k do you feel like you're withdrawing yeah because I've got the shakes you feel shaky yeah he seems slightly agitated and anxious which is understandable being in hospital but also becoming an animal foreigner we'll get you some good anti alcohol treatment alcohol withdrawal treatment before you're in the hospital with us I suspect what's happening is that your body is metabolising alcohol and when it does that it shifts your metabolism to prioritising managing alcohol and the liver becomes unhappy and produces a lot of lactate and that lactate is building up in your body making your blood quite acidic and your body tries to get rid of as any acid it can by making you vomit does that kind of make because stomach acid is very acidic yes so it produces lots of acidic stomach acid that you then bring up a way to try and manage your acid base disturbance exactly and that's why you're bringing all that stuff up I want to have a look at your liver with an ultrasound machine which I'll come into in a moment but for the meantime you just need loads of fluid you need to eat something to try and give your body a bit of glucose to recover things you can have some intravenous glucose once you finish the vitamins but you can't have any until you finish the vitamins that makes sense if you do then you're at risk of bad things causing your nerves you really do need a lot of 10 I don't think this thing's not working so you've got some nice vessels in here if you just put it in the same side as this 1 is that alright yeah that's okay because you need these vitamins you're on the heart size let's see I've got little bit yeah chest x-ray have you had a chest x-ray yet 3 I'll make sure you have 1 that's fine and that's it behind the palate do you feel soreness in your tummy oh it's sore up here it's sore up here we'll do 1 more time I need to take you to another ward so that they can monitor you a bit closer because they can't keep you in good time I'm gonna quickly look for my legs no edema no rashes no tenderness brilliant thank you quick stiffness so can I see your tongue if you can ask me fine no it's not too dry yeah not too dry so your weekend is left after your vitamin d sorry I'm gonna continue with that so you should have some intravenous vitamins yeah have something to eat and I'll give you some glucose after you've had your vitamins to get a full amount that yeah plagued that on normal does this have to run over a certain speed I have to know I'd be yeah think I'm good did you manage to get 1 in oh was much easier that side you've been fine yeah it was really good it was honestly so much easier that side oh maybe that's funny I'm just trying to get bit of oh done I didn't wanna get my nervous fund just so we don't lose it yes please so I'll have that right okay okay good yeah I'm sorry yeah please I know great so I'll go and have a look at all your results and things I'll make a good plan for you being in hospital a bit more fluid a bit more of those vitamins to make for over the next few days to make sure that you're not deficient in any because that can cause high lactate levels right we will yeah your lactate levels are coming down with treatment which is really good so they'll continue to come down I'm sure with time off the alcohol with the fluid and with vitamins okay but just just yeah need to keep a close eye on you really alright your ph is nearly normal so that's good to be done right okay so I'm going to sleep here tonight hopefully not an a and e but in the hospital tonight okay is that alright sort of sort of okay yeah I'm worried about my neighbor coming and not being able to find me I see is that alright shall I call your neighbor oh yes it is have you got a phone yeah phone's down I can I can just set you up on it oh is that alright oh no yeah yeah I know have to call there yeah here we go this thing I wish I had a I know yeah can we get some water oh no I love that part so impression is lactic acidosis secondary to alcohol misuse disorder improving at risk of alcohol withdrawal no evidence of chronic liver disease on recent no evidence of liver cirrhosis on recent imaging plan admit to hepatology ward number 2 serial blood gas measurement until ph normalized number 3 intravenous vitamins number 4 intravenous fluids number 5 following intravenous vitamins encouraged to eat number 6 alcohol withdrawal management with seaweed number 7 abdominal ultrasound number 8 add lipase ggt ast onto bloods number 9 if develops abdominal pain low threshold for cross sectional imaging