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Hi is that miss gemma pickering hi I'm doctor vooroop miller I'm 1 of the gastroenterology registrants hi how are you have I caught you at a reasonable time good I'm glad can we can I just confirm your date of birth is that alright fantastic great great we've had a referral from your gp but I'd love to hear a bit about your symptoms and we can work out what we can do about it mhmm mhmm mhmm wow mhmm mhmm in terms of when you eat something you could feel it going down and then you're feeling your stomach right okay in what way does it affect your throat mhmm mhmm mhmm and the pain is in your throat or in your tummy in your tummy okay okay mhmm mhmm because because you feel like you're worried about getting symptoms alright okay and how much do you weigh at the moment and how tall are you mhmm okay k so 6 months of symptoms and you say it started with constipation do you still feel constipated do you still feel constipated and normally it's what's normal for you okay you feel like food's stuck right and that goes along with the bloating and and the tummy pain that you've been having okay and going back to your bowels you you said you open them at least once a day and what what do you pass is it a formed stool is it loose is it firm loose okay how loose is the the toilet entirely water or water with small ragged bits mushy you have to rush to the toilet is it did you have significant urgency no urgency fine any blood or mucus and do you ever open your bowels more than that or fine get constipated if I understand yeah fine and you've been taking that antioxidant medicine the ppi and but you said you didn't feel like that had been helpful in terms of your okay okay that's good I see alright okay and at the time of your endoscopy did your stomach look inflamed at all let's have a little look at it no it didn't look it looked lovely fine okay alright so your your blood tests are quite reassuring that you had after the endoscopy and obviously the endoscopy that shows things that are normal structurally is quite reassuring but obviously these symptoms sound quite significant and and obviously having symptoms every day is horrible and the weight loss you're having is along with it so think some more tests will be really helpful to look into what's causing these significant reflux symptoms and also your weight loss I think that if your bowels haven't changed that's reassuring over this time? But it's still I think investigating a change in your bowels associated with significant weight loss is is sensible and looking with a lower gi investigation like a colonoscopy I think would be quite helpful to look into why you're passing mucus and why you're having these changes to your bowels associated with weight loss you've had some blood tests recently which showed good kidney function so there shouldn't be any reason that you didn't take bowel preparation and there's other good tests here to look for a cause of constipation and I can't see anything here to cause that or certainly a change to the bowels if that doesn't show an underlying cause then I'd suggest we look to do measurement of the pressures in your esophagus and the acid levels at the lower esophagus we can talk about that with the result of your colonoscopy and and take it from there is that alright of course it is so at the bottom of the oesophagus the tissue the lining of the oesophagus meets the lining of the stomach and we call that the 'z' line I'm not sure why but we call it the 'z' line an irregular 'z' line shows that there's it's not a straight line and there's a slight waviness in the line however it's not a significant finding and it's very normal it may be indicative of having reflux but there's no sign of a significant change in that in that lie or anything worrying there does that kind of make sense and does it happen with certain foods or just all the time and do you ever get food getting stuck or difficulty in swallowing food okay but the food get does go down but you just feel like it gets stuck yeah and that's in your upper chest or your lower chest or okay alright it's interesting certainly that's when we looked there was nothing no structural problem in your esophagus if you feel if if you feel like things are getting stuck and things do actually get stuck I think it's worth looking into that again and doing another endoscopy but I think if you feel like things are resting around the bottom of your breastbone it may be that your slight hiatus hernia is trapping a bit of food and that can cause those kind of symptoms okay yeah okay certainly but no fair enough yeah of course yeah yeah I think let's let's get that lower gi test looked for the reason that your bowels have changed and you're losing weight and and take it from there is that alright okay brilliant alright it was nice to talk to you and we'll talk to you again after that alright brilliant bye bye so I had the pleasure of speaking to miss pickering on behalf of professor lewis in gastroenterology clinic today on the telephone full stop her symptoms started approximately 6 months ago where she was constipated for 8 or 9 days and then she was experiencing worsened acid reflux upper abdominal discomfort and heartburn full stop she'd been taking ppi but didn't feel this was working for her full stop paragraph over the last 6 months she's lost a significant amount of weight going from 15 to 11 paragraph she reports feeling nauseated a lot of the time alongside her reflux symptoms and she also experienced upper abdominal burning pain and water brush sensation full stop <\n\n> She her bowels haven't changed over the last 6 months however that's just not true over the last 6 months her bowels have changed she's increased frequency from 1 to 2 times a day to 2 to 3 times a day with associated mucus and they can be quite loose full stop there's no blood reassuringly and no significant urgency full stop <\n\n> Yes intermittent symptoms of food resting behind her breastbone however she doesn't experience episodes of food bellies obstruction I wonder this is due to her hiatus hernia full stop <\n\n> That reassuring upper gi investigation and some reassuring recent blood tests however the continued weight loss and change in her bowel habit associated mucus makes me concerned about a lower gi course for her symptoms and so investigating this with a colonoscopy would be prudent full stop I'll arrange this for her following clinic today full stop <\n\n> I look forward to seeing the results of this and we'll see her back in clinic with those full stop yours sincerely investigations ogd feb april 20 25 but dyspepsia irregular zed line at the goj 37 centimeters above a small hiatus hernia gastric polyp otherwise normal stomach duodenum normal

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Medical ST5 Miller Clerking
[Current Date] [Current Time]

Presenting Complaint:
[The reason for attendance in 1-3 words]

History of Presenting Complaint:
[Chronological narrative of current illness using short, clear sentences. Include:
- Onset, character, location, radiation, timing, exacerbating/relieving factors
- Associated symptoms
- Impact on daily activities
- Previous similar episodes
- Relevant collateral history from relatives/carers
- Any relevant background from other healthcare professionals
Do not repeat patient's name throughout. Be concise and tell a chronological story to the reader. Do not include subjective descriptions of the symptoms e.g. "severe" or use unnecessarily long words.]

Past Medical History:
[Bulleted list of significant medical conditions with relevant details:]
• [Condition with year if mentioned]
• Diabetes mellitus - latest HbA1c: [value] mmol/mol ([date])
• Asthma/COPD - latest spirometry: FEV1 [value], FVC [value] ([date])
• [Previous surgeries with dates]
• [Other significant medical history]

Drug History:
• [Drug name] [dose][units] [route] [frequency]
• [Example: Omeprazole 20mg PO OD]
• [Example: Clopidogrel 75mg PO OD]

Recently Stopped Medications: [If relevant]
• [Medication] - stopped [date/reason]

Allergy History:
[If allergies mentioned:]
• [Allergen] - [Reaction type] ([severity if mentioned])
• NKDA [if no known drug allergies stated]

Social History:
[Living situation. Who they live with, housing type, if mentioned]
[Mobility. Walking aids, stairs, transfers, if mentioned]
[Carers. Formal/informal care arrangements, if mentioned]
[Occupation. Current/previous if relevant, if mentioned]
[Smoking. Never/Ex-smoker/Current - pack years if mentioned]
[Alcohol. Units per week/Never/Ex-drinker - if mentioned]
[Functional Status: Impact on activities of daily living, if mentioned]

On Examination:
[General Appearance. Alert, well/unwell, distressed, if mentioned]
Observations:: [If mentioned - HR, BP, Temp, RR, O2 sats (do not use subscripts)]
• Abdomen: [Inspection, palpation, percussion, auscultation findings. If not commented upon, document as normal]
• Cardiovascular: [Heart sounds, murmurs, peripheral pulses, oedema. If not commented upon, document as normal]
• Respiratory: [Chest expansion, percussion, auscultation. If not commented upon, document as normal]
• Neurological: [If examined.]
• Other: [Any other relevant examination findings, if mentioned]

Investigations:
• [Test name] ([date, if mentioned, do not include include today's date on results, list without a date]): [Result without units]
• [Example: Hb 85]
• [Imaging type] ([date, if mentioned]): [Key findings]
• [Example: CT Abdomen/Pelvis (15/03/24): Sigmoid diverticulosis, no perforation]

Impression:
[Main diagnosis]
Differential Diagnoses: [Only if multiple possibilities discussed]
[Secondary issues. Relevant comorbidities affecting management. If mentioned]

Management Plan:
1. [A numbered list documenting the management plan to be undertaken, if mentioned, include:
- Immediate management/monitoring,
- Investigation requests,
- Treatment interventions - medications, procedures,
- Discharge planning/follow-up arrangements,
- Patient education/lifestyle advice,
- Referrals to other specialties if needed,
- Which ward or specialty the patient would be best admitted to e.g. "Respiratory Bed",
- Escalation plan that was discussed - whether the patient is suitable for CPR, ITU and/or NIV.]

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