Hello I'm mr stokes I'm doctor miller I'm 1 of the gastroenterology registrars nice to meet you how are you good are you sorry to see you at the hospital yeah and I see you're in hospital with us going to the next very short visit where you had some high blood sugars and low magnesium levels you're weaning off any home after that is that right and what's been happening this time well I just got home I haven't eaten anything the last time I had was last night oh okay so how about sunday no sunday today yeah yeah sunday today so yesterday saturday yeah alright so you left hospital yesterday morning hey but just because we don't have any I don't have your notes from then unfortunately yeah I went home mhmm and I went to bed and a cup of tea because I was really and then in the morning what was it blood okay not red blood no black other than black jet black like this screen like that that black okay that was like blood to me yeah digested blood melina is what we call it nothing else well there's nothing else left in lost any appetite just don't wanna eat lost my appetite yeah well like I say it came early little bit no it stayed down k that was cold I said yeah I'm cold and I'm your markers of infection in the blood are quite high certainly higher than they were when you left hospital right okay might be an infection somewhere but no cough or cold or anything like that no passing water or difficulty passing water no no any rashes at all that you've noticed or anything like that I still have my tummy k and can I have other medications do know yes okay so you can have ran up but I've got cancer and weekly chemotherapy yeah and and not cleanses so you can spread to your bones in the area and any other medical problems so diabetes don't you no anergic to anything no no I see your hands that's no what did you do for a living you said you've done some work yeah yeah so in in this hospital yeah right how's everything been in this hospital for 15 years I was maintenance all my way around oh good fine but yeah I've been retired now for I don't know so it's a lot of it's really so not had much of an treatment gone away mhmm come back I'll have a quick listen to your heart there's enough people complaining say again I said there's probably enough people complaining you're right about that felt and then just stop there for a second feel it to roll over onto that side for me ever so slightly yeah okay 2 breaths in take the breath all the way out then hold it great breathe away it was a little bit of a heart murmur but you were told to ask me please it's very subtle and very very quiet all the time I've been in bought my taking anything metformin anything and no pain passing water no good so I'll just sit forward and have a listen to your back yeah okay I'll just see you in case you're sick sure good and you're be with as much as possible yeah so like I say markers of infection in the blood are high but to examine your advanced urine snort and blood counts are best they've been over a while yes your hemoglobin's 71 today it was 65 last week seems like you have digested some blood it's not a fair what are you gonna say something well when I was here on saturday cameron lee and I said I'm waiting time if you wanna go home you can and I I wanted to go home good but I wished I had because I thought I had an infection I didn't yeah because I went home did meet your blood tests from when you were in hospital over the month yeah they were on the they were coming up hindsight do you know what I mean yeah I can only see that trend now I see your blood test yeah actually that increase the mark of your infection I think in your blood because it's a patient of infection to your cancer yeah but yours are much much higher than they are than they were the other day right okay okay yeah I mean you're you're on top of it anyway of course yeah no so I think yeah please screen for infections look for a source of it I know you do I've had it before exactly it's not very nice it's not very nice no and it does come with said the same thing I think our threshold to do the alkaline your score from bleeding it would be high enough to keep you in our case that's good because I rip in have you got a pen in there no right I'll ask them to put 1 in there and take some blood so I can give you some intravenous antibiotics to treat any pain in the back no nothing much so you should be coming around for a cannula I'll ask them to it I can do it fine yeah yeah so I won't go back on the emergency team well yes we get the practice I mean people are difficult yeah sure so I'll leave the light pressure and classical history for gi bleeding but biochemistry and hematology not compatible or less compatible however calculating glasgow vatra score will be high enough to require inpatient ogd given second presentation I think this is sensible investigation to perform number 2 raised inflammatory markers of unclear source plan number 1 septic screen number 2 iv antibiotics number 3 iv fluids number 4 dietetic review given lowered nutritional intake number 5 blood cultures number 6 patient ogd number 7 wide bore intravenous access number 8 if hemoglobin drops below 70 for transfusion number 9 not for ppi until ogd