Next patient is julia stone 419496 we have investigations list blood test july 2025 normal tsh normal b 12 and folate normal ttg normal ca 1 2 5 normal and gallbladder april 2025 gallbladder thin walled echo free no sludge stones or wall abnormalities seen appearances upper gi endoscopy des or oh sorry colonoscopy december 2024 sigmoid was fixed and uncomfortable but no colonic cause was seen apart from very mild diverticulosis undertaken for rectal bleeding internal hemorrhoids noted upper gi endoscopy december 2021 undertaken under general anesthetic normal gastroscopy apart from likely simple fundic cyst biopsies biopsies nice to meet you too have a seat thank you how are you better than I was oh good I have to say I'm glad so tell me I hear you've had nausea when it last tell me all about it hundreds it all started really I suppose from december I had a: yeah it came down with nothing apart from internal mri hemorrhoids mhmm everything was okay then until march march april I was mhmm my my weight went down I had no appetite affecting my everyday life really fatigue but in what way did you feel unwell 2 I think is that why your appetite went down even yeah and that's why my appetite went down of course however I know I was not well at all look the loss of weight was quite significant I think at the time how much weight had you lost I can't remember that's okay then I wrote about it but I know I've lost bone in this year maybe mhmm I think it's this year k because I'm normally about staying heavier than I am now you're eager to put on weight but then it kind of subsided mhmm and I did have an appointment to come and see somebody and a reminder that it was still available so I thought you know what I felt better and then july year it all came back again and similar things really and + I developed this throat problem yeah I've got something I've actually got a letter with me that they that they wrote to me probably a vocal cord palsy on 1 side of my throat mhmm yeah right above the foot pulse level is normal and then when I was talking to them I said to them I'm getting burning in my throat and just below that area as well so they had a look at my throat and they diagnosed this that was it thank you okay they had a look at your throat they said you had a bit of vocal cord palsy yeah and then the burning when did that all work the burning has been there since the july if I'm honest but I just thought it was because I was unwell because sometimes I know my voice does go a bit burning and they suggested some gaviscon but I might have a silent reflux that's gonna cause vocal a lot of mucus or something in the back okay fine mhmm so I started taking the gaviscon twice a day after my evening meal and at night got better than later I'm doing a bit more but it's not it's still not I still don't feel as if my appetite is all over the place some days I can eat reasonably well other days I don't feel like anything I work that happens quite a lot where I work up though you're not sure how every day to day it changes not really no a lot of things I used to like which were healthy things I now don't don't fancy things like that okay and what kind of things do you eat tell me about your diet I usually try and have porridge and fruit mhmm I usually have a sandwich but I don't eat too much because I don't like eating too much why is that because it's a bit of a block mhmm here you get that burning pain behind your breastbone like you had before when you lie down no no went to see my gp yesterday and the ent people said both of what they they mean or thyroid that what removed half yeah half of my thyroid removed and what might that be the weight loss what linked to did you say so you went to your gp and they said that it's all linked to the thyroid but what might be linked to the thyroid no it's okay my train of thought sorry I threw you off past me a question what was I going to say ent said to me k so because okay of your chest of my chest so he's done that fine but I just feel generally not really myself I used to walk my I used to walk and walk is it linked up to gastroparesis I don't feel as well as I should as well as you'd like to yeah no fine and anything in your diet does anything in your diet flare up your symptoms mix it into glucose I'm gluten free ish anyway because I prefer to be that way and it gluten just blows me out okay if I have it so I've been not a 100% strictly I do have the the odd thing yeah for all but you've been tested for celiac disease and I still have this normal I've been but some people can be intolerant yeah yeah without being yeah and cream and ice cream I'm not I can't just go through it it has done for years how are your bowels my bowels are for a year or more I have an urgency when I wake up but it's not in a diarrhea way it's in a slightly but I do have an urgency and it it's very regular every morning every morning but it but it's almost like as soon as I wake up and and I come 2 that's it mean interesting thing and what happens you go to the toilet and you sit down yes and then what happens it's normal most of the time a bit constipated yeah do you have to strain the past the skin occasionally but not but not often mhmm and what kind of stuff comes out just we can use some pictures no not really we will buy it if if we if we like the look at it varies a little bit to be honest mhmm that yes and that okay fine soft clots that are passed easily yeah sometimes mhmm depending on what I've been eating I suppose that's fine yeah but they vary between type 4 and 5 yeah mhmm depending on what you've been eating do you ever get periods where it's type 1 or type 7 or is it it's never not on a regular basis never liquid never liquid I can't remember the last time I had a diarrhea episode mhmm but is it sometimes this very hard to pass like little lumps occasionally how often is it occasionally I don't know yeah every couple of months or so mhmm okay fair enough okay good I guess I just wonder whether obviously it's all linked together isn't it yeah our gut health is all is all linked and how things move through our gut can impact how things yeah and what you describe about feeling that food is sitting there at the top of your stomach yeah I wonder whether it may be indicative of the bowels not moving well from the lower end but it sounds like they are yeah I just want because of the hemorrhoids that he had some they're indicative of straining that stool mhmm and whether an underlying constipation can be driving a bit of your symptoms as possible but it may not be yeah in terms of the tests that we've done I saw that you had an ultrasound of your gallbladder which looked fine yes and you had you've had a lower and an upper camera test over the last 5 years or so yeah your upper camera test was in 2021 and it didn't show anything structurally wrong there which is good and your colonoscopy was also reassuring that was great some talk about ct scan but I don't have the result of it but it was I had a yeah I went privately in the end actually so I was so worried this was back in march april time that I I was beginning to think maybe it was more because I have had a few problems there as well okay and not normal yeah yeah they didn't. Out anything at all great well that's reassuring as well isn't but it is this is is getting me down a little bit I mean the whole I just don't I don't know whether I've got a psychological I know it's very linked isn't it it's very linked very much and I have considered that I even thought I had an eating disorder at 1 time but I don't have an eating disorder because I want weight and usually people with eating disorders see themselves bigger and want themselves to lose weight don't they completely I've gone through certainly our mood can affect our gut and our gut can affect our mood in ways that we don't really understand but I and everyone's do realise that yeah well I guess there's many ways which we can tackle this I don't think I think given the recent ct scan colonoscopy and upper camera testing that's very reassuring that there's not something structural yeah causing you but I don't I can't tell from those tests whether you've got gastroesophageal reflux disease where you get acid reflux into the palate right and certainly a lot of the symptoms you describe could be indicative of that we have that objective evidence of the vocal cord palsy which can happen because of acid washing up over the vocal cords right and what you described of not being able to eat a meal late at night because you go to lie down yeah maybe you're having reflux and possibly not feeling it in your lower gullet I don't feel ever the reflux I don't feel the the acid up in the throat or anything you'll ever get that feeling of acid coming into the gut but you do get that burning feeling I do get this in my throat it's burning and you've found the gaviscon helpful which again- I have found the gaviscon helpful it's towards the potential for excess acid causing things mhmm and obviously our appetite is linked to the symptoms that we've got if you're if you've got terrible symptoms of nausea you're not gonna want to eat and if you've got excessive acid that can make you feel really nauseous I wonder whether a lot of this is gastroesophageal reflux disease right for that you're on some gaviscon which can work really well other things that can work really well are things like proton pump inhibitors things like amethyl metisoprazole which can be really helpful they're 1 of the some of the most prescribed drugs ever yeah they can work fantastically well to suppress the acid production in the stomach I think we're targeting symptoms and I think how much you take it and for what duration you take it should be guided entirely by your symptoms things change and as we know it's linked to our gut our gut and our brain are linked together what we eat everything's all very variable and how your bowels are doing will determine how much you need to use it but I suggest having some on your prescriptions when the symptoms are bad take it for 2 weeks 3 weeks being on medicine in the long term is probably not good you want to be healthier and putting you on medicine forever isn't a way to make you healthier I don't think my late husband was on omeprazole for years he ended omeprazole and stomach cancer there's lots of talk about omeprazole because it is 1 of those very highly prescribed medicines yeah and but there's certainly no evidence that it causes stomach cancer as far as I'm aware in fact it's protective against stomach cancer because we know that lots of stomach cancer is driven by right inflammation stomach from acid have you got any family history of that with of stomach cancer no no that's good so what heart on on my side of the family mhmm so heart disease and I can't see that what I was going to say is I can't see that we've ever tested you for a bug which can cause stomach inflammation called h pylori right so I'd suggest before we start you on the omeprazole we test you for that because once you start omeprazole that test isn't as reliable as we'd like okay so it can be a good thing to get done if you're thinking about starting omeprazole right and then I think try it and see if it improves your symptoms yeah and I'm not suggesting you take it every single day I'm not suggesting you take it at all if you don't want to but I think take it as and when you need it as that kind of rescue therapy I'm feeling nauseated yeah and my appetite's going have some omeprazole because I want to feel better right but not necessarily take it every time to take avastin all the time it's fine to take avastin all the time it's not absorbed no all it is is it's an alkaline substance right with something that reacts with acid and produces gas and then it's captured in a foam so it's a foam former and an alkaline substance it neutralizes the acid in the stomach and with the gas that's released it forms a foam which acts like a cap over the acid in the stomach so if you're having reflux that cap will sit at the top of your stomach and stop things coming up into your gullet because your stomach is fine with acid but the gullet and the oesophagus are very sensitive to acid often people have oesophageal hypersensitivity where they feel very sensitive to even small amounts of acid other people can have really terrible reflux and not know it so I think targeting symptoms is important I think trying the omeprazole could be really helpful I think trying a good regular bowel habit will also improve your general gut health and what you say about bringing the fibrous foods off makes me wonder whether you might be slightly constipated so often people try a natural laxative prunes fruits and seeds along with their breakfast you'd have porridge in the morning you could try adding some chia seeds or some flax seeds on the top which are right excellent nonabsorbable fibers that will try and bulk and soften the stool slightly right to try and improve your overall gut health and I try those 2 things together right and see what see if you can improve your symptoms that way okay okay think I'm reassured that your weight's not dropping off you at the moment it's not now it's stable it's stable that's ever since I've been on the guts con yeah strangely enough exactly so I wonder whether a lot of that is driving your symptoms does that kind of make sense yes it does and I don't I don't think another invasive test will change anything are you okay with me having the ct you can you feel free to have the ct that's absolutely fine course ct yeah no that's very good yeah right I mean in terms of a camera my own peace of mind be honest I understand I think yeah that's fine and when you've got obviously had that experience with your husband horrible experience with cancer it's gonna play on your mind yeah I completely understand that yeah all of our tests have been so reassuring I don't think there's anything structural causing your symptoms endoscopy wasn't done recently though no it was 2021 it's true quite a while though it was but I don't think that another invasive test will change anything you're not okay you don't you don't sound like someone who has a cancer to me right given your weight stabilized we would see continued weight loss okay okay alright incredibly severe symptoms yes that would be unresponsive to medical therapy so I really don't think that's what's causing things okay I think the ct scan of your chest will also be really reassuring because it'll see your esophagus in your stomach yeah and if there's nothing to do I don't think rushing in to do another cam I think the easy thing would be to say let's do another camera test yeah but I think it's an it's a horrible invasive test and I don't think it'll change anything I wouldn't have it without a general anesthetic anyway I just couldn't bear it so that's comes with I guess increased risk for anesthetic yeah that's right for for and I don't think it'll I think we can change that decision and revisit that decision if you're taking omeprazole and your symptoms are terrible you're having really terrible weight loss okay that we can't control with medical therapy then I think that's entirely reasonable and the goal of that would be to take some samples from the small intestine to make sure you haven't got something like coeliac disease causing things but I think we can revisit that at a later time if things change you can always get back in contact with us right you know via our secretaries and we'll book you to patient initiated follow-up if you like so you can get in contact with them and come straight back to see us okay and we can revisit things okay that sounds as far as this other blood test goes then when what what would the other blood test the the 1 you mentioned it's a stool test oh just stool test yeah and I can give you a pots and a label for it today there's a pots you can send it back to your gp okay and then I will get the result and I'll write to you with it when it comes back to me okay fine does that sound alright yeah that's fine great I can find the form it's always a bit weird when you're coming for the because obviously my my other august 1 was cancelled here because of lack of stuff or whatever it's always weird coming in when I'm actually feeling a bit better yeah unfortunately the factor of our we get used to practising like this because our waiting list is so long it's miserable we actually end up seeing people a lot yeah our first symptoms are already better yeah and that makes it very difficult to remember what to do to have but it doesn't mean we don't need to investigate them no totally yeah totally let me put it in okay have you done a stool test before do you know how to do it I've done the the the ones that you get delivered to your home delivered to home yeah fine so this is the ones that you get through your home there's like it's like a test strip that you wipe on the stool this I'd suggest go to the toilet put lots of paper in the toilet yeah go for a poo yeah and then there's a tiny spoon okay just get a tiny spoon and then screw it back up and then I'll put I'll give you a label to stick on the side pop it in the back return it to your gp okay and then they'll send the results back to me and you should do that before you start any omeprazole just so that it's very sensitive so the next food you go through starting these omeprazole will that go through to my gp I'll ask your gp to add it to your repeat prescriptions I can prescribe you some now if you'd like to pick up at the hospital pharmacy if you want to that's okay I'll wait until get him in actual fact you know I think I've got some at home okay great fine you can try taking 20 mg of but you didn't want me to start that before I would have netafib you do give us a stool test and then you can start omeprazole to see if that improves symptoms excellent so bag label 1 goes in the front of the bag and then this 1 goes in the top okay right brilliant on the back okay okay okay thank you I look forward to seeing that I'll write you a letter with everything and I'll and then I like I said I'll enroll you to patient this year you've got a lot you can come back and see us anytime right if the symptoms come back things get worse then we can book you our next available slot and see you very quickly and do I contact direct or do I go through my gp contact us directly it's gonna be a letter for the secretary it's at the top the number for the secretary's at the top of the letter just call and then book you into our next slot okay so you don't have to do that whole thing thank you so much I'm waiting again thank you was a pleasure to meet you thank you thank you you very much for your last diagnosis most likely functional dyspepsia but to exclude p pylori infection and manage empirically for gastroesophageal reflux disease shit I have the pleasure of meeting missus stone in gastroenterology clinic today on behalf of doctor neil full stop the consultation was face to face full stop <\n\n> Her symptoms began in march or april with decreased appetite, feeling generally unwell with nausea and over that time she'd lost over a stone in weight over the course of the previous year full stop there was no disturbance to her bowels and reassuring her weight loss is now stabilized full stop <\n\n> Her symptoms resolved but then started again in approximately july with a retrosternal high burning sensation full stop she saw the ent team in august she diagnosed a right vocal cord palsy and wondered whether there may be an element of gastroesophageal reflux disease and suggested gaviscon full stop her symptoms have improved with taking gaviscon but she does have daily nausea and bloating full stop <\n\n> We were able to speak about her diet, she is nearly gluten free but I note that her previous celiac serology was normal full stop she has porridge and fruit for breakfast, a sandwich for lunch and a small meal in the evening because she doesn't find that she's able to lie flat after a large meal bed full stop paragraph he you know in terms of her life more generally, she's bravely opened up to me about the loss of her husband which and so the concerns about cancer are obviously playing on her mind full stop <\n\n> I'm reassured that her gp plans a ct thorax for her in light of her previous thyroid operation and I'm sure that will visualize her esophagus and stomach well to exclude anything concerning here full stop <\n\n> We were able to talk about her bowels she has urgency in the morning but without loose stools and usually tends more towards constipation full stop she'll pass between a type 4 and 5 stool although stool can intermittently become type 1 to 2 and she'll open about once a day full stop <\n\n> She had a recent ct scan of the private patients which was which she tells me was entirely normal full stop unfortunately I'm not able to review we had a long discussion today about the potential underlying causes for her symptoms full stop I'm reassured that her weight loss has stabilized and I don't think another invasive investigation is the right route here full stop given her symptoms have improved with gaviscon it's possible that gastroesophageal reflux disease or indeed functional dyspepsia are driving her symptoms full stop <\n\n> I've we've agreed today that we'll exclude helicobacter pylori with a stool test and then a trial of omeprazole to manage any esophageal reflux disease full stop I advised her to take this as and when she has symptoms as opposed to taking it regularly full stop <\n\n> If the helicobacter pylori test is negative and she doesn't have an improvement with omeprazole then I suggest seeing a dietitian talk about her diet it might be the next step in order to and then keep an eye on her weight full stop I'll enroll her into patient initiated follow-up and she can get back to you at the top of the letter if she wish to see us again if her symptoms deteriorate full stop you're still sitting thanks very much so next patient allison bowman 749298 diagnosis list as per the letter june 2024