• Medications, especially any new ones (don’t forget TPN, OCP, herbal and over the counter meds).
• Alcohol history.
• Risk factors for viral hepatitis, e.g. ethnicity, Hx of IVDU.

• Examination findings: signs of chronic liver disease, decompensation, portal hypertension, right heart failure, BMI.
• Note if a patient is newly encephalopathic call the gastroenterology registrar immediately.
• Sepsis, hypotension or right heart failure can also cause deranged LFTs.
• Liver panel.

Hepatitis BsAg, Hepatitis BcAb, Hepatitis BsAb.

If HBsAg positive, add Hep BeAg, eAb, and HBV DNA.

Hepatitis C core Ab.

If positive, add HCV RNA and genotype.

If acute hepatitis: HAV IgM, HBV Core IgM, EBV and CMV IgM.

AMA (primary biliary cholangitis).

ANA/Smooth muscle antibody/ anti LKM (autoimmune hepatitis).

Immunoglobulin A, G, M levels (autoimmune hepatitis).

 Panadol level.

Iron studies.

Caeruloplasmin and serum copper (don’t do if over age 40).

Alpha 1 anti trypsin levels.

Conjugated bilirubin +/- haemolysis screen.

• Ammonia level if relevant (e.g. Encephalopathic).
• Ascitic tap (incl. albumin/protein/WCC + differential).
• Relevant imaging e.g.: Liver ultrasound or CT triple phase scan or MRCP.

• Trajectory of liver test derangement. (E.g. have outpatient ones to compare with.)
• Calculation of patient’s Child Pugh or MELD score.
• JMOs coming up with their differentials along with information that supports or disproves their case.

• Not thinking about what pattern of liver damage.
• Forgetting extra hepatic causes such as cholestasis of sepsis, heart failure, ischaemic hepatitis, and haemolysis.
• If they don’t know already, ALWAYS inform the liver transplant team if a transplant patient has been admitted under you (even if it is for a non-transplant issue).