Next patient julia lewis 412593 66 year old lady investigations hemoglobin 99 when heme when hemoglobin was a 100 on the october 30 92 on the 20 ninth and a 103 on the october 28 mcv 68.2 which has been gradually declining since july 2024 platelets 374 in the normal range neutrals 11.32 from 5.92 and white cells 14.9 from 8.8 renal function tests liver function test bilirubin of 5 otherwise unremarkable crp 5 urea 10.8 when previously was 4.2 so ct abdomen and pelvis august 2024 long standing severe atrophy of the left lobe of the liver appearance is the first part of the duodenum unchanged mild wall thickening extended towards the liver hilum with some associated tethering to the residual atrophic left lobe mri small bowel partial gastric outlet obstruction likely due to fibrotic stricturing of the pylorus / d 1 long standing scarring and tethering in this region to the atrophied left lobe of the liver in the past medical history recently admitted from the 20 seventh of the tenth to the 30 third 1 with a right sided pneumonia anemia and recurrently vomiting on a background of known transient gastric outlet obstruction she had a single episode of diarrhea but no melena she started on amoxicillin for a community acquired pneumonia she was all switched and then sent home off when she wasn't vomiting when she was discharged he's known to the gastroenterology team with recurrent episodic intermittent vomiting probably due to a degree of functional gastric outlet obstruction related to scarring in the first part of the duodenum related to either previous ischemic liver injury duodenal ulceration or pancreatitis but no endoscopically visible stricture mri small bowel we've already discussed previous alcohol related hepatitis and cirrhosis on biopsy from 2,000 and long standing alcohol abstinence previous post ercp pancreatitis in 2017 treated for possible cholecystitis / cholangitis and not felt suitable for cholecystectomy in 2017 long term back pain on btech patch is anyone from the liver perspective medications list not available currently magnesium's listen also not available chest x-ray rotated film impression of an object projected over the right chest hey b okay alright okay can we can we talk to you tomorrow or something actually yeah yeah I'm on I don't know maybe the doctor's going to give me a lip home yeah well I'm going in a minute this one's in the back of my car yeah okay bye and you love you both bye okay okay who's that you're speaking to it's my best friend from ria mhmm but she's making such a mess for life at the moment why is that well you know she didn't use well you know because I I asked her straight out I said are you drinking mhmm because a couple of people have been down to the house during the day mhmm and you know you I mean you recognize signs oh really that's my business yeah yeah course and also that and they they hide their glass and they put their back too because dan who listed me was at he the went down there because he's just written a book and she was going to do it for him you know to get it all done right and he was down there and he said she kept turning around and having a sit with her back mhmm yeah not a good sign is it although I'm rob by the way I'm 1 of the gastroenterology doctors it's nice to meet you and you I think you know doctor bat from clinic lovely doctor bat yes but yeah I know better well doctor george doctor george yeah from before yeah and then you handed over from doctor george to doctor bat right oh I see because doctor george is just about from time he doesn't have been back to me he said gosh you know you were here when I started and you're here when I finished but I think he's done a good job then don't you think not actually really I'm truthful no because I don't know if you've noticed about him which I feel is very important when you're talking to a patient etcetera and that that you look at them but when I was visiting him after I was released he you could see he wasn't taking in who I was as a person no right and my circumstances so the next time I went said to him I I see you had a haircut and you could see his face absolutely change in a good way or a bad way a good way in a good way because then he's a nice guy yeah no after that you had a human connection yes but he was he was bad before because I don't know if you'd ever got to meet doctor lowe's no never oh he's fantastic really he was so he used to be so patient with me because I'd try and put some makeup on and look really healthy and he'd sit there and listen to me dripping on and I said well can I go home then he said no very good no he's but I loved him he was so he's the 1 that taught me all about drinking mhmm what not to do it what to do it well but he what he was saying is it doesn't bother me your life because I've seen thousands of people he said but you know what you've been through and what you've done and that what a waste he said and so I went I think probably about 15 without drinking at all I was talking to doctor chopin my doctor who put me in hospital when I was dying and I said to her about the odd drink like at christmas or you know whatever and she said well look you know it's sad life if you just can't have it odd you know and then I started thinking about because you hear that alcoholics once they've had 1 that's it it's difficult isn't it it's difficult when you get that taste for it but and I got frightened then mhmm of it and I didn't touch a drop but then I don't know what happened but I've just became okay with it I I wasn't frightened of it anymore oh yeah because my drinks cupboard at home for other people is full I'm not tempted 1 little bit that's good and I think well I think it is good but I think I myself have got very low tolerance for alcohol mhmm in that you'd get quite drunk more than you no I never did but I was ill for days after mhmm it's funny isn't it because we don't really understand some people we see them in hospital yeah and they have no liver problems whatsoever but they've drunk so much that they've destroyed their brain that's what I mean and they get wernicke's encephalopathy and other people have no trouble with that they drink so much that it destroys their liver and some people don't drink a huge amount but it still destroys their liver so there's there's something that we don't understand about which people are susceptible to alcohol in terms of liver damage and which people aren't and it may be something to do with the gut flora that's what lots of the research is about well that's who I was just talking to because I'm you know aiming to take it seriously because 1 of the tests I don't know it was doctor lowe showed me but he always wanted me to go like that and look at my palms yeah and to make sure you haven't got a flap being confused no the red yeah to look for palmar erythema yeah and do you know it's gone now great good you look very uncomfortable can I do something to make you more comfortable I feel so ill if I move you away from the wall we could lay the bed down a bit flatter and you could slide up the bed and then you wouldn't be so crunched up because the bed's set up for someone to sit sat and bolt upright no I but you're not shall we do that what is the plan well that's what I came to talk to you about you're vomiting blood I hear yeah did you need to cut this morning don't get out today a liter and a half came up and how do you know it was a liter and a half when I was admitted to the I've made the bed down it was 2 2 back to an hour you had a moment and what came up last time because last time you were admitted was the october yes yes you can write I write my name is nathan and going leave you flat so you can slide up I've got 3 discs out in my back and I'm so caught from my doctor knows it this is not doctors chopping no no she's directly descendant of doctor shu pan really yeah that's so good it shouldn't be doctor shu pan yeah 1 more time it is you pronounce it properly no that's fine you stay there don't go off your chair back okay and now we get up hot how's that well it's you want to be faster than that yes please drumming my mind a bit more that's okay yeah is that comfortable or okay okay it's been so crazy I'm sorry it's badly affected I sort of you know it's I told you this more I was crying and I said I can't focus anymore it's not a lie I haven't been out of the house for 9 years so last time you came into hospital the october you were vomiting blood yes is that right how much came out about 2 litres and what colour was it it was very dark dark coffee ground yep fine and dan said when he put it in the toilet it went black okay fine and this is the same this time yeah but was not a bright red vomit like my shirt like pieces in there like skin or something but not bright red like my shirt no no no no no no oh like a nice dark color like my shoes yes good that's better is it I was told by the a and e team that you'd had a bright red vomit no but that's not the case excellent no wasn't you know you're here to help me and I appreciate no no of course and I wouldn't waste any of his time no no no you're not wasting my time I'm happy you're in hospital I'm just I just want you to clarify what's treatable go because I said not going so you've had an liter and a half of dark vomit this morning yeah and then how have you felt otherwise have you had any fevers or anything like that well my my head feels hot your head feels I don't think I've got a temperature any change to your bowels at all well I've I haven't been I've eaten nothing mhmm since you came out of hospital well since I went home mhmm over the last time a bit to you know because I was told by the dietitian to eat stuff that my stomach wouldn't have to work at digesting things that are a bit liquidy and thin I was is that what were like a liquid diet sorry you you what are you what kind of things did you eat over the last week com plan yeah I thought you were doing liquid stuff yeah 5 years at nighttime because you have to give yourself a treat I'd have a slice of cheesecake cake but what I'd do is just have a little tiny bit and that would last me all evening mhmm and when's the last time you went for a poop I had peripheral diarrhea so I'm not expecting and what color was the diarrhea it was quite dark but there was no blood there's nothing because dark like jet black and tarry dark or no no no I've seen that you've seen that so it's not the lena no no no no good some blood alright so you've had some loose stools today just today feeling it you know like it's coming out mhmm because before I didn't even know mhmm I didn't know at all till they x rayed me yet yeah yeah and and and on your x-ray I can see that your lung fields today look clear it doesn't look like you've got chest infection but I can see something projected over the right hand side of your chest are are those your breasts or do you have something on your chest just your breasts yeah just your breasts that's fine because you were lent over and it's it's the projection of your breasts there's nothing on your chest other than your breasts that no no that's fine don't need that no no no don't worry there's nothing nasty there it just looks like half your lung is full of stuff but I think it's probably because your breast was over the top of it it looks like it you you tell me what to do with it I'll do it that's fine alright can I have a look at you do you mind no I'm looking at your hands and listening to your chest and things like that I like your tattoos when did you get them done when I was about 11 or 12 with a pyro and a needle was in new zealand that's where I come from oh right cool I didn't know that whereabouts in new zealand are you from island mhmm which apparently has disappeared they've had dreadful storms and floods really god I don't know if you know new zealand I know of it know it's beautiful beautiful place because I like just being on my own with the dogs know the open spaces I and there's a beautiful place called kykora and you can go there and you can get taken out now but it leads to the sea and you can see the whales going through and the seals all over the rocks it's so gorgeous I need to get out there oh this place by my brother's house and it's you you then even it's really weird you don't even put your hand in the water it's so pure mhmm and they've got a thing about it on the thing when I was reading it and it comes right up from the very very bowels of the air or and it worked that's why it's so pure and you know I just think it would be it just I respect things like that yeah yeah amazing oh I'm so you know so what made you move here I hang on I got married to a baroness and we lived in and you met scotland and you met in new zealand yeah mhmm but I'd had a little baby oh yeah that's nice no it's not and how old is your little baby now the little baby that was 18 by 2 weeks when I had him alright 77 so he worked out himself mhmm and that's his nightmare mhmm but that on the spectrum okay you know but he is very very cheap like that mhmm and then knows exactly what he's doing yeah and I he told his brother I said oh I have a nice note from nathan mhmm I said he said he's gonna see us all at christmas won't that be nice and they they were oh no we don't and what's your life like now who do you live with at home well I've just got jan there he's been with me for over well just after my narcissist relationship finished who's jan jan they call anybody that's been in the navy in the southwest jan janis yeah janis or whatever yeah janis and he spent 25 years at sea and he's absolute he loves I've got 12 acres and the the lawyer didn't want him you know plant an orchard but I said well I'd say it's okay I don't mind and but he was there while the children were going up and I could go back to night school and college and I got my degrees and things like that business management fine good have a quick listen to your chest go on lovely can I listen to your back do you mind if you sit forward and how about smoking do you smoke I vape now you vape fine can I feel your tummy yes you can it's out it that's horrible you know when I had the liver you had liver injury probably and then now you you've got an outlet gastric a outlet obstruction oh I don't know but I've all had to that out and it was poison I can't hear anything there that's fine okay it doesn't sound like you've got the fluid now it looks like it's all sounds like it's all come out it was just a cough mhmm because when they wanted to x-ray me I don't know why they wanted to do that because I don't have any symptoms yeah and then they came back and said oh you've got pneumonia yeah fair but I've been on and have your water worked any pain passing water no no no no no nothing at all great okay good yeah well you're a bit anemic were you became a bit anemic last time obviously obviously I'm going to be anemic aren't I why because I've been sickled that blood I don't think it's blood don't you I think stagnant stomach stuff I think what's happening is your stomach isn't emptying because you know you've got that gastric outlet obstruction because of the narrowing in the first part of the duodenum yes most commonly when people vomit dark brown stuff it's stuff that's been in the stomach for a really long time well guess that you know it's been lying around because I said to the other doctor we didn't really have time I was a bit upset because I said well where is it coming from where is it I said I don't know he said but there's nothing we can do anyway alright walked away okay well think and I do think that your vomiting is probably because of this gastric outlet obstruction thing as opposed to bleeding well doctor batts said no cause 1 of his colleagues I saw I was supposed to see doctor batt but stood in and this is after 8 9 years and I'd go and see him for an appointment and this guy came in honestly I could have cheerfully chucked him out my window and that he said well I see your gallbladder's been removed I didn't know that oh yeah we're keeping your gallbladder in aren't we because it's stuck behind your liver yeah with major veins yeah yeah lying on top and they said we just it's a bit of the liver yeah consultants said we wouldn't even go near it hello oh my god it's my child hi I'm rob 1 of the gastroenterologists hello good to see here's the main man I'm not the main man that's alright but I work for doctor yeah he's your consultant oh okay he's he was busy I guess over halloween really you think so doctor bat oh of course he was of course he was yeah no very good you're too quick quick very good you're too quick oh yeah no you are extreme very good so what should we do about that everybody's you know worried about me and they don't know know because hamish has got 3 children and he is working and that and his wife works and he lives over in kingsbridge and so does lachie and so it's really samantha that sees me the most doesn't she yeah so I think the main problem and correct me if I'm wrong here is that just the the living conditions comes in at the moment yeah I didn't hear much about that so tell me what are yeah well so do I mean the house itself from the driveway is tricky enough to get into you've got to go down concrete steps in the like in the front door but the mom obviously because she can't really get around that much she has to spend most of the time in bed which is up the stairs and she can't get up the stairs and the only help she's got because obviously all the rest of us are wherever we are is an 86 84 year old man who's jan yes jan yeah fit as a fiddle no I I just thought I said that but it's it's just a lot do you know what I mean so obviously this keeps going round and round in circles like mom will get a little bit better and then she'll go home and then all we're doing is really waiting for a phone call but I don't this is no one's no one's no I was telling him I was telling him you know because we all know about my alcohol problem but you know I don't drink no no I don't think any of us think that's what's going on no I'm just that some of your doctors and doctors first thing they say and it's really really it's put so much work and effort into getting away from it so what is I'm I'm interested in what you've done since you came out of hospital about a week ago you've been in bed the whole time have you got out of bed at all yes I to go to the loo to go to the loo which is at the other end of the house so it's a fair fair it's well it's a bit of a war and how about food what what do you eat well because jan can't cook so I have okay I think I told you you said you're drinking and maybe a bit a day you have 2 2 5 in a pint okay and enough then yeah it's not a huge amount is it no no I wouldn't I wouldn't say that's enough to maintain you do you think nutritionally complete you don't have enough of them yeah yeah they are I think I'm fat I don't think you're fat I don't think you're fat I think you have you have a difficult nutritional state you probably have a a a deficit of muscle certainly on your blood test looks like quite low amounts of muscle yeah and often yeah I was told about that by this psychiatrist who'd done a survey on this baseball team and she'd put them in bed for 6 months to see what the muscles I thought yeah I'd really want to hear about this so I think you need to decide so obviously you've had lots of tests you've had that ct scan I just don't feel hungry though yeah I know and I wonder whether the stomach isn't emptying very well because of this strict I think you've got the duodenum me that 1 that's asked he said oh I see vetigo or bladder removed he was showing me and he wrote he he just drew a not very good 1 you know we're not judging day job very artistic and it was sort of like there's a pocket up that everything's fallen into your stomach it pumps things out of it into your duodenum the first part of the small intestine and for you you've got a narrowing on that mri scan you had of your small bowel we saw that it was narrowed in the first part of the duodenum we looked with a camera it looked alright but I wonder whether we need to look again with a camera and see if things look different because I think it's in your back oh it's that purple thing because I think that if things if the appearance is worse there's something we do about it endoscopically we could open it up with a balloon for example yeah that's what the doctor was on but I honestly I'm terrified be to hospital so who knows is it I just what I've got to think about because I've watched I read this story about no it's a documentary about this woman that had been put to sleep but they hadn't put her to sleep properly right they'd or they'd given her the first drug which made her she wasn't couldn't move I mean I don't know anything about her but and then they opened up her tummy and that and she was awake all the time sounds horrid yeah and I sort of have nightmares about this of course I've got it's a very isolated case mark it does sound it's like a very isolated case it doesn't happen along about it it doesn't happen at you know what I'm live well the camera test we wouldn't put you to sleep anyway no I know I've had enough of those you know I'm quite happy with that suggest that's what we do not to look for bleeding because I don't think you're bleeding but I think that you no you make sense but I think that the trouble is that your stomach's not emptying stuff sits in your stomach for a really long time and then you vomit up all of this dark stuff and it's all of the comp plan that you've been having all of the food you've been eating that's just stuck in your stomach and not able to get out because of a problem with your that's why I said I eat a cheese cake like I do you know a small mouthful and then you know I watch telly and let it go through let it go through yeah but it may be just sitting in your stomach and the reason you may not feel hungry is because your stomach's already full it's just not getting into your small intestine stomach and I suspect that's what's going on explain it so I think the best way to investigate that would be another camera test to look for a narrowing that we can see with our camera because if we can see 1 with our camera then we can open it up I'm not a balloon I'm sorry if I can't but that's what I was you know what I I mean yeah that's what I'm saying and that's what I'd suggest to try and fix the problem is it all my faults and nearly dying and everything I've never had an operation yeah I'm not suggesting an operation at this moment I'm suggesting just have a look and open it up on the inside I did tell that fix your problem but I think it's a big a bit of an undertaking for you with everything else that's going on with your liver and that so we need to have some serious discussions about whether that was the right thing for you no that so it sounds good to me know good you came to see me it's absolutely fine really really am because it's it's so frustrating I know and I sympathize with how busy you are mhmm and how precious your time is it's not precious it's fine it's nice to talk to you amazing I will I'll add a few tests on to look for other markers of malnutrition in your tests I'll ask the dietitian to come and see you as well I'll put you for an upper gi camera test to try and get you to our gastroenterology I've got malnutrition because because you're not eating while ago I had the same problem and when the ambulance no I'd fallen and jan at 85 cannot pick me up and when the crew got there of them the technician really knew his staff and he went through and he saw the big bowl of sick and it didn't smell of anything but it was sort of kind of like porridge being made with water right and there was kind of slippers in it and he said do you know what that is he said that's your body trying to feed itself sure your face much through the stomach a bit of water maybe but not an alcohol and not much else so you really need to get it into your small intestine in order to absorb it so next time I see him I'll say so I think it's all made made up up doctor rob miller says you're a liar tell him alright any questions or anything else are you allergic to anything I should have asked no no not med medicine no good you've got that sorted would you be able to because I'm really really cross about it what because I've got 3 days down in my back oh yeah and the doctor's taken my patches away and I was on 15 mhmm and he's now reduced them to 5 and it's not working mhmm and if I go this is why I can't go up and down the stairs because you're in pain oh it's like a rug of iron you know and it throbs he's now taken away my sleeping pills we're terrible aren't we no no it's not that I do I don't know if you'll remember I do have a habit of sleepwalking fine I didn't know that the opiates will slow your stomach down and they'll make it more likely that your stomach doesn't work so I can see the logic in decreasing it no that's that's fair enough I can try and put you on something in hospital yeah but it will slow is there anything else that I can take instead of good but they do have lots of side effects they do slow slow gut motility quite significantly yeah I can understand that exactly it's the last thing you want yeah I just it would be wonderful if I could go riding again of course alright I'll go and get everything sorted job is but you do realize julia you're 66 I said oh thank you for reminding me and you've had to look forward to more support thank you very much I do really appreciate it that's alright and I hope you're bit more comfortable than I can for taking to us I'll leave it to you every day alright what did you think about going home I'll come you know come in I I was refusing to come oh but you know I felt so dreadful really did I don't think you made a diagnosis or solved the cause of your problems so I think it'll be a bit of a waste of time to go home I think yeah thank you that's fine but this happened before and I did I said to you because hayrich reckons I forced mhmm you know then she gets that up and then she just decides fair enough it's not my birthday like I did I sat and thought through it mhmm and the nurses said you're very ill julia you're not wearing much wear home and that that was and I sat and thought it through and I thought I'm feeling very selfish for janet home 85 because he's woed to death right absolute worry and you know and I thought I've made up my mind then it gives him a break and I'm too ill I decided myself I was too ill later 2 the nurse comes and says pack your bags we're moving him down to the departure lounge fine it wasn't my choice no no fair enough what do we do about that going forward then is that just down to us to sort out like mum's own life I I think think it's it's something something we can sort out while we're in hospital yeah yeah and I'll ask the various people to get involved yeah look at that I'm gonna have the medicine but I'm not very good at this today I hope so so I'll let them do that yeah thank you that's okay I'll ask them steve thank you see you guys soon thank impression gastric outlet obstruction secondary to known duodenal pyloric stricture second presentation within 10 days to 2 weeks unclear underlying etiology for worsening in gastric function on examination heart sounds normal that's alright now we're going breath sounds are chest auscultation normal abdomen no secussion splash obese soft and nontender mild peripheral edema to the ankles bilaterally smells unkempt plan number 1 liquid diet number 2 if vomits for ryle's tube number 3 discussed with gastric consultant marne regarding role for upper gi endoscopy versus functional tests such as barium swallow to ascertain level of duodenal stricturing or gastric outlet obstruction number next iv fluids number next stop antibiotics number next hallatin ward had the impression no clinical or biochemical evidence of gastrointestinal bleeding anemia which persists from the previous admission likely nutritional and for further assessment and add to the plan hematinics b 12 folate ferritin and transferrin saturations stool charting food charting