So next patient steven epworth 5 8 7854 77 year old man ct thorax abdomen and pelvis are taken by the urology team because of a t 3 prostate digital rectal examination reveals low density filling defects in the left lower lobe lobe and segmental arteries with further full smelling defects seen in some of the segmental and subsegmental arteries in the right lung appearances in keeping with pes has been seen in urologic clinic today where prostate felt to be smooth plan for continued finasteride therapy other investigations nuclear medicine bone scan no metastasis bloods from the sixteenth demonstrate high deficiency anemia a program to check-in there sorry I'll see you there you pop in here I'll pop you in close you pop wow how much is this oh you're better slightly bigger because that one's really small difficult with the chair we've been wearing this been 1 1 yesterday didn't we no 1 next to wearing I'm doctor miller 1 of the clinical registrars nice to meet you have you got with you your wife I'm guessing yes yeah exactly I saw that you went to the urology clinic yeah and they're quite happy by the sounds of it that what they yeah said to yeah fine that they were worried keep taking the tablets and keep the catheter yeah exactly and then but I think they were hoping to try and take the catheter out at some. Is that right at least 3 months 3 months at least 3 months okay because I've gotta take because I've only been on the tablets for about 2 for 2 or 3 weeks I see fine okay and then to give him 1 of tablets those that he's on for his post rate for another 3 months 3 months mhmm and then come back and see the doctor in 6 months I see which is really really good news because because we're worried about something sinister and worrying of course yeah yeah really we start with you all in the kitchen and you thought get the warning off of it of course of course you worry about that I know but yeah but it's all seems to be going really well so that's really good okay and why did you have the all these tests done what were your symptoms I I was oh 8 weeks 20 yeah I was at home I couldn't do it at all at all right and all of sudden what's an hour wasn't it yeah 20 over 20 hours anyway and then called 111 they sent an ambulance out eventually right and they took me straight down to check my lung they didn't take me in today he said look look I said I'm what's happening he said I'm I'm great and when I got down there they were waiting it's all the doctor in the nurses fantastic and they've kept me up with a catheter and all of a sudden just awful the relief is great isn't it yeah blood everywhere really okay but it all cleared now good just come from a bit water now and the doctor did an oral test this morning and he seemed quite happy great that's really good based on that you may have blood clots in his lungs yeah that's what you're here for the blood clots in the lungs exactly so you you had urinary retention you had a catheter blood came out now you've got the catheter it's draining well yeah have you having any other symptoms recently no no been feeling fine I I I was back along I was passing out but okay I found out that was because I was checking these propofol I was on that monday but I was a foreign name yeah and then but my blood pressure my blood pressure got so high yeah down too low that you were passing out was passing out I see alright because he had severe diarrhea when he was in in mill mhmm and they actually sent him home with diarrhea really really bad okay so he never sent him home with and said you know get on with it mhmm with no care I've done I've done literally everything it's sorry it's brenda's upset because I'm disabled as well so brenda's a bonkers really and yeah so it's true and fro true and fro things like that when he used the toilet when he eventually went over to the toilet he fell off a bit quick and obviously his blood pressure would drop down dropped down so he's learned now that if he uses the toilet to do anything else he just sit there that was sometime again wasn't it yeah yeah was very 4 weeks ago oh 4 weeks ago yeah I was you know mostly 2 and a weeks yeah okay oh fine I didn't even see that from your notes but I mean this must be a strain so you started him on a friday and that happened on friday night and that's again on the sundays and but everything else seems fine does it it's hard for me to yeah certainly so your blood tests show you're quite anemic has anyone told you about that no nothing really works very good I'll show you the results I'll take couple of months for you to check on so you can have a look at them but the counts look relatively low it looks like your iron levels are low which could be before god say again it's only got was it weight or what it used to be what your blood counts yeah and everything seems to be changing yeah and then obviously you had this test showing you clots on the lungs yeah well I'm on aspirin mhmm and well my doctor put me on another tablet for my heart mhmm because I've got 1 part working faster than the other okay well I I don't atrial fibrillation is it that's right yeah that's it have you got my that's okay I've got it on my phone in case anybody asks yeah yeah but and she's gonna put me a new tablet but she said she didn't wanna do it until she heard from the chestnut so which tablet were they gonna put you on a blood thinner like a pixaban yeah fine that makes sense yeah so obviously if were they gonna do a biopsy on your prostate gland or something we wouldn't wanna start you on a blood thinner no because obviously you'd have to stop it again yeah but given it doesn't sound like that's what they're gonna do no you said well 6 months ago see him so it's so the the blood clots on the lungs can be serious but in your case they're very small and very peripheral which is quite good they're not causing any damage to the heart and your ecg the tracing of the hives is good yeah so that's very reassuring but we just need to treat the blood clots on the lungs with some blood thinners and they're the same blood thinners that we'd use to treat atrial fibrillation so they're the same exactly the same medicine it'll do 2 things in 1 kind of thing right exactly and keep the blood thin enough that you won't give yourself a stroke with the atrial fibrillation yeah don't need another 1 yeah and then you'll also treat the clots on the lungs but it does take time to treat them it won't be a silver bullet they take sometimes months to get better completely but as long as you keep taking the tablets things are I've got no chance I'm not taking it us doctors are all the same aren't we same as the urologist just keep taking the pills I've got no chance every time he's an eye on you you're begged for lot us us men all need that too begged for a lot we need that and I sit there and sort of do his tablets for him so so there's your blood counts so back in the may your blood counts were fine and then since then at the june they've just been dropping down so said it was completely changed didn't they and these high platelets make me think that you're low in iron levels we haven't tested 100% that you're low in iron levels I don't know if anyone has no one's tested I can add them on oh no they were ages ago weren't they the seventh fourth fine so I think you should have some more blood tests to look for whether the iron levels are low and if they are low we can arrange to give you an infusion of some iron or starting on some iron tablets to try and bring your levels up yeah question will be about whether you want to investigate the cause of your anaemia so in some people with an iron deficiency anaemia there's a cause and they're bleeding from somewhere slowly somewhere in the gut often I did have bleeding in the prostate given your urine's cleared up it seems like it's unlikely that that will be causing your anaemia for all people with iron deficiency anaemia we would talk to them about whether they'd want to have tests for that so that would be a camera test or 2 camera tests if you wanted to have them 1 down your throat to look into your stomach to see whether there's something bleeding there and 1 up your bum to look for something bleeding there obviously you've had this ct scan of your tummy yeah which is a pretty good test to look for cancer in the: which would be bleeding and you haven't got any sign of: cancer which is good it's not the best test for it the best test would be a colonoscopy and at that time we get to see everything in excellent detail and be nearly 100% certain that there's nothing worrying there we can be relatively certain there's nothing seriously worrying there from that scan obviously it's a much less invasive test exactly so that's very good news the question will be whether you'd want to have an upper gi endoscopy to look for whether there's anything bleeding in the top end it's up to you really we know that in a third of people that we do these tests on find something that's caused their problems not always something sinister there could be a bit of inflammation in the oesophagus or gut disease in the small intestine etcetera etcetera and those kinds of things we can treat and often we can treat at the time of the endoscopy but it's very dependent on how well you are and whether you'd want to have that test done because he's just cancelled an appointment now with his eyes because he should have an operation in his eyes so he's cancelled that long enough to have that done cut with that until I had the results because I didn't know whether I had cancer or whether it of better or course yeah understand 1 thing at a time and they get horrendous 6 7 weeks once us doctors get our claws in you don't let go we're terrible yeah we do more tests and find more problems and offer more tests for the problems it's a vicious cycle yeah yeah so sometimes you can more say than you lose more weight yeah some people say I feel fine at the moment and that's how I want to stay and I don't want to have any invasive tests yeah some people say I couldn't go home wondering whether I had something sinister in my tummy and I'd want that excluded and everyone's different it's all about your approach to risk so if the alternative is you're going to close centers and I can tap the term exactly as you it's challenging isn't it we thin your blood if you're bleeding from something you might bleed more blood counts might drop further we should really need to thin your blood because these clots in the lungs can progress to something life threatening so that's very important I've got to have it in the heart anyway you're not having a life threatening bleed at the moment which is good whereas disease could be life threatening these clots so that's number 1 priority but number 2 priority is thinking in the back of our mind that we might make you bleed more from somewhere with our blood thinners and that might drop your blood counts further a difficult 1 and you don't have to decide today how about we'll get some blood tests today if that's okay to look for can I be done here on it we can do them here yeah yeah to look how bad the how much the anemia has dropped by we'd start you on some blood thinners after that if the anemia is very bad then we'll say maybe we don't start you on blood thinners now because that's very risky but if the anemia is stable as it is then you can start on some blood thinners then come back to have your blood test taken again say on monday or tuesday to have them recheck to see if your blood counts are stable on the blood thinners aspirin you can continue the aspirin they're different medicines they work in different ways 1 stops the blood from clotting and 1 stops the platelets from sticking together although the blood clots after the platelets have aggregated the aspirin is very good for preventing a stroke whereas this blood thinning medicine doesn't prevent you having a stroke in your brain but it does prevent you throwing off a clot from your heart if that makes sense they work in different ways so he needs to take aspirin as well osprey just need to check that because if you're giving him different tablets then I would be panicking do you take the aspirin the aspirin is something that's been around yeah exactly it does thin the blood but it works in a very different way to these other medicines you can have both at the same time so we're gonna have a look at what other medicines you're on even raw drops anyway I think so what do you think try these tablets do a blood test the tablets and come back saying mom do you yeah see what's happening sounds great and see what's on monday for another blood test she's another load great I need to make sure we're here for the blood test or come here for the blood test need to make sure we're open I'm pretty sure we are on monday and then we can see because of the strike boy exactly because of the strike yeah well that's strike 5 open now yeah everything is isn't it everything is yeah my father used to say what about parties in the working man's or within the mire and I think I think like your doctors and nurses and waiting and going you know there isn't enough money in the world that oh because I think you're just amazing you know you save a lot a lot of lives you know things and things that get there mean there wouldn't be assistance anywhere over there you know no it's going to stay football would only get 50 gram a day I know yeah if only I was any good at it what I used to be but I can remember when mark went professional when he got 13 a week fine I'll put some blood tests on for you I'll ask them to grab some tests for you and then we'll it'll take an hour to come back so I have to hang out for an hour to make sure that your blood counts haven't dropped significantly is that alright yeah yeah we've been in hospital sometimes since we're on insulin know I know I'm sorry I'd have hoped that they've taken some blood tests from you in clinic but they haven't and then we will I'll get you some blood thinners good blood count for a k alright and something for is it you wanna give him something for you here yeah I'll get you some iron tablets to start if you're bleeding from the top end we probably don't wanna give you iron tablets we give you a drip of iron today that'd be quite nice wouldn't it that'll give you 3 months worth of iron which would be lovely it be really nice instead of taking 3 months worth of iron tablets we'll just give you a shot of iron today given you're here we a in we can put a cannula in when we're taking the blood test give me a drip of iron which takes half an hour and you'll feel much better I reckon that'd be better than taking the iron tablets if you're bleeding from the top end they can irritate the stomach more than iron tablets right we do that then so is that alright yeah yeah sounds like a plan I don't mind needles and I've I've had so many of them more than years ago yeah I'm sorry it's not bad just 1 of those things yeah I usually get into trouble because I can always remember a nurse saying we bend over her and I said you know and she said what I said oh stick it in my neck so I can watch you sticking it in she said what I said just stick it in my neck what do you mean like to see just so you could watch it go in yeah I won't it's not more than me oh fine okay hate that if my toe's amputated jeepers creepers really awful did they know you'd woken up yeah they just said goodbye yeah yeah I just got surgeons just at the bottom of the bed there just cutting their toes off and they went oh just go back to sleep after I went well that sounds scary oh isn't it 2 grandchildren oh definitely do they like stories like that it's a scary story for a grand kid our our grand our great grandchildren but fuel at all do formula one's soccer racing really wow junior soccer racing amazing liam woolie they just smash into the wall tip parts of woolie just get out and say come on in rent the car quick quick do the thing amazing great I will I'll pop you next door to have the blood test taken take the nurse is that okay yeah it's okay no problem yeah we got the maybe from you won't have so much metal you use got all your own big magnets yeah you very much okay no she's a off she's a few apparently she's just gonna try and move in alright yeah just okay let me make some contact okay just wipe you on it just this chair here lovely job thank you very much I'll do some back out here and then tell them to grab some blood tests and see what happens okay I'll see you in the few minutes lovely can you everything would you like to be