Mister david hookins 609367 a 91 year old man investigations albumin 34 creatinine 109 at baseline no electrolyte abnormalities live remainder of liver function test normal crp 63 urea 10.4 ast normal magnesium normal full blood count platelets 145 but they've been low for some time lymphopenia but otherwise normal full blood count venous blood gas unremarkable in the investigations we can have upper gi endoscopy july 2025 benign esophageal narrowing at 20 centimeters but esophageal malignancy at 30 centimeters ct chest abdomen and pelvis t 3 n 2 m 0 esophageal cancer features of pulmonary fibrosis radiopaque gallstones in a thin walled gallbladder aneurysmoid abdominal aorta 3.7 centimeters left sided groin hernia just at mdt on the in july 2025 poorly differentiated adenocarcinoma reviewed and for best supportive care and esophageal stent reviewed at hot clinic at the july has been seeing doctor cogil for palliative radiotherapy 20 gray and 5 fractions completed in september 2025 with palliative intent at the time of hot clinic was eating scampi and chips however swallow has deteriorated and only having liquid food and small volumes of that with associated weight loss and subsequently went for esophageal stenting november 27 it is just 3 days ago had to use a nasal scope due to impassable stricture at 20 centimeters wire passed into the lumen and stent deployed under radiological guidance checked the scope and proximal end in good position radiologically no obvious signs of significant stricturing in the lower esophagus medications list aspirin 75 once a day benadryl flumetiazide 2.5 mg in the morning omeprazole 20 mg once a day atenolol 25 mg once a day medical problems past medical history ckd 3 b cell non hodgkin's lymphoma from the left eye coded in 2013 hypertension myocardial infarction 1994 total hip replacement on the right 2012 no known drug allergies on gp system sorry it's miss houckes yeah hi I'm rob I'm gonna go back to the emergency room was continuing to see this who do me daughter daughter flusty you're welcome rob how are you you good yeah I'm sorry to hear about the trouble after your stents sorry lasty business yeah you mind if I pull the curtain and we have a chat about what's going on thank you tell me all about it what happened oh it took a lot longer didn't it to get it in sounds like it was challenging very tight yeah that took it told me about 20 minutes and it was an hour before I got it in unfortunately I couldn't see anything because it was so tight so you had to use a wire under x-ray guidance place a step in it looked like it was I the right wasn't there I read the report but I wasn't there moved to my bosses today I did feel I needed to be having a job to do it because a couple of times I felt I presumed it was something like a not a candle stick a knitting needle it felt like a needle was inside yeah oh I'm sorry it's horrible going in whatever it was I was pushing it in with into my stomach a couple of times I'd be coughing you don't have any sensation in your esophagus you can't feel any pain in it no but stretching it moving it blowing it with air can be pain can be interpreted as pain and obviously we used our very small camera so that can be a bit more irritant irritant than our big camera because the pressures you can apply through a tiny thing are a bit higher than you can through a bigger camera does that does that kind of make sense yeah I'm sorry it was difficult and then what's happened since you had it done 3 days ago on 20 birthday yeah thursday and then on friday I got guilty about friday yes but then from then on things got worse I've got this you feel this lump here all the time and I kept getting the pain in it pain at the top yeah if I spoke too much and seeing it well it just come on sometimes when it doesn't yeah always had a good appetite and always had plenty of energy yeah and I lost control mhmm sorry I just can't you know I keep trying to drink and eat but I've only got to take a little drop now I begin to feel sick feeling nauseated after so yeah so I then you know something more because I'm in the right kind of ringing up and you're worried about being sick have you been sick no very good he hasn't been sick he's just he's so thursday night he had obviously a restless night I think I got on the night yeah friday morning yeah me and my daughter went over and and I got onto claire with the gi yeah team yeah she phoned the doctor's surgery who then phoned me half past 5 on friday and arranged some morphine okay because of the pain that he was he's just getting this pain coming along in waves in waves yeah it was what was I giving me morphine was it good before oh before that it was paracetamol just yeah dissolvable paracetamol which wasn't doing anything and was did the morphine help no well I suppose it did in a way and cut but it made me feel right he said he felt bronchitis just lean back there in there it will do that unfortunately that's what I said to him it that's what it's designed to do to make you just chill out yeah and it's it's an excellent painkiller yeah but that seems to then made him feel sick yeah of course still didn't seem to stop the pain the number 1 thing is pain in your neck and you say it comes in waves is that right well comes when I talk when you talk alright not not now because what you've given me I suppose but yeah they come on the way I've put it and it doesn't get on its own sometimes you know mhmm but he's still here what we're finding there danielle alarming is the fact that he's not drinking mhmm before eating but I think since he's been home he's had some stomachs oh yeah hi hi someone join us please I'm here have a couple of spoons of soup mhmm that's it eat a couple of since we put it in on yeah thursday yeah mhmm and that's it of course and and what do you attribute that to is it the pain is it the nausea yeah both yeah both really yeah mhmm and if you force yourself to have something does it go down yeah and it stays down yeah that's good yeah I do know that I have opened it a bit yeah it's much more open 76 hours 74 hours yeah 72 hours takes time exactly yeah to stretch out completely but it's the not drinking and the dehydration of course and he's at home obviously we don't live with him so he's got my mum but it's having its toll on her and the dehydration is the part that's worrying us I mean he's 91 yes of course he's already lost a stone and a half since september and we're trying to we keep telling him to drink and eat but the 1 place it's gotta go down is the place that's bothering him yeah and he's just not drinking and eating he thinks he's drinking a lot but it could be that that much for a day mhmm that same to drink or eat it does go down it does so I know I have opened it a little bit yeah yeah yeah it's opened up quite a fair amount can't get it down because feeling sick yeah I take 1 you what I've done scrambled egg this morning mhmm because you thought I could get bit better a bit but I could get it down but then as soon as I got up with it down I wanted to bring it back up have you tried anything for sickness he's had some today he's had some and are you feeling better having had that yeah that's good right I'm glad I'm I'm just I'm just trying to stop it that's not really me and I was making myself scared I'm just what I'm concerned about is if he gets sent home yeah course we can't monitor what he's drinking and eating that's perfect and at the minute I just think he needs to get his fluids yeah of course we need to make you feel better such that you're able to drink enough is all yeah exactly this will be good yeah some good anti sickness and trying to push you to drink as much as you can will be good unfortunately your esophagus is designed to move and designed to be flexible it should open up when you have a swallow of food it will close down again it's a stretchy tube that helps connect the back of your throat to your stomach and what we've done to that lovely stretchy tube is put a massive metal rod in it which is incredibly uncomfortable and and unfortunately it is often people will say they've got pain often people will say they feel nauseated and crap afterwards I'm sorry okay it's not often people feel nauseated they feel crap afterwards they get pain as you're describing I think it's important to make sure it hasn't moved because that can sometimes happen yeah your ct scan it wasn't that tight at the bottom so there's always the potential that the stent can slip in the first few days of it being in before the tumor has has grabbed onto it so we should do an x-ray to make sure that it hasn't moved and if it does look like it's moved we should get you to drink some x-ray dye to make sure it's going down and see where it's going that's the first thing we should carry on with the fluids get you some good anti sickness and try and get you to eat something and drink something to try and see if we can get on top of your oral intake because that's what we need to do is make this stent work you've got the stent now make sure it's in the right place but if it is we need to make it work and that's gonna be with some medicines to make you feel better anti sickness medicines because having a big rigid tube in your esophagus makes you feel nauseated yeah and when you need something to make you feel better from that perspective and you need some painkillers for that pain you're experiencing in your neck which will get better as the oesophagus stretches out it will accommodate to the stent but it'll take a few days at least that makes sense the doctor has looked at me today he did which is I was glad he did I don't remember and he looked down right in there was a torch and and he's pressing both sides here and he said it was in place it was in the right yeah and sent into the wrong oh sure I don't think we'd be able to see it the stent the top of the stent's at 25 centimeters yeah so it's it's bare way down yeah we won't be able to see it without going down with a camera no not by looking in your throat or we could with an x-ray because it's made of metal so it'll show up but she did do that anyway yeah I was glad that somebody looked down yeah of course yeah and then the pressing in the sides I mean the heart would be pressed of course even if I hadn't got this I think if he had pressed hard I'd feel something yeah for sure so I didn't want him to press and I didn't really feel anything unusual and they asked me about what was it pain down here and the pain here but no there's nothing pain down here yeah you just can't the shoulders getting a a little bit of that pain now shot doing it again like I said you don't have pain sensation in your esophagus so this could be reflux because we overcome the top of the stomach with our stent so it naturally should be tight and we've opened it up you could be getting loads of reflux which can make you feel uncomfortable so I'll give you loads of antacid medicine you could try some or some sucral fate which can both help you feel make things feel better and I'll make sure you've got some good painkillers because it could be referred pain up from the esophagus does that make sense yeah yeah fine your markers of infection in the blood are a little bit high it could be because of the cancer are you feeling alright in yourself no no you got any cough or cold yeah no trouble passing water no yeah you got see I'm in the front of your hand the other side so okay sorry other side it'll come back in a bit do you mind if I have a quick look at you do you mind if I look you know with this what you have around your neck that's that's chest and and move back that's why I was gonna do the same thing alright can't trust those in the doctors they're very nice I'm just joking you can sit where you are if you could sit at home yeah how's the same your lovely and ready for that last 1 is it 10 and + when I wanna come 5 that sounds good you can then call that up and listen to your back if you're able okay thank you big breaths whenever you're ready thank you I'll be able to do it I'll call now I'll get your rest back put your coats behind you under your head put that back down is there any challenge you want no k cutting up here and pressing down can feel the tip of the stent no you can no I can't it's a good thing it's probably in place in your chest where it should be it's really little bones there mhmm never has to be able to when I was having the right weight you lost a lot of weight I think I'm sorry this is the trouble with esophageal cancer it's not the cancer that gets you it's the trouble with eating that gets you yeah make sure that you restart your fluids so I'll carry on your fluids I'll x-ray your chest and your tummy and we'll find out where the stent is yeah I'll get you some good anti sickness some good painkillers get you feeling better try to eat something I'll I'll encourage you to order some soup or something soft and liquid that will go down yeah I'll get them to give you some water so that you can try something I'll give you some antacid medicines some strong omeprazole through the drip to see if it's reflux causing these symptoms I'm keen to try and get you thought I thought these were yeah you're having some just some intravenous fluid to rehydrate you yeah not 1 at the moment you the other 2 yeah you probably did have some anti sickness medicine at 1. Yeah yeah I'll have a check and see what you had what do you say I'm keen to try and get you out of hospital because I don't think that taking the stent out or doing anything invasive in hospital is the right thing to do and if we can make you feel better get you eating and drinking and make sure the stent's in the right place I think we can achieve that and we'll try and do that today if we can yeah okay but obviously I'll make sure that you and your family are happy with that if we get to that stage and you can always stay at the edges that sound alright yes any questions or anything I've forgotten I don't think so no I should ask you if you're allergic to anything no no no that's fine you live at home with your wife yeah do you drink or smoke no no clean living clinic what did you do for a living I was a panel a panel beater yeah like for cars yeah and he's brilliant was james young I don't know if you remember james I haven't heard that I lost a mix london I lived in london there whereabouts in london you've a london accent east london intense accent I was in intense bromley bromley yeah my family are from bromley I grew up in twickenham yeah so yeah not far yeah I've worked there on an apprenticeship there we've worked there for a few years mhmm on hand retail yes I'd done that again in the army you know master service of course and then I come out and was there again for a few years what year were you born '34 '34 so you've you've seen the last part of the of the second world war I'm sure you wouldn't remember it I'll remember it right do you remember it oh yeah the gold was what was I around 30 '4 5 years old when it ended no obviously that avenue when it ended upstairs of course okay 45 started started sorry my dates yeah I think you're wrong I wish you remember yeah yeah no I was in my family right mhmm so I remember the blood form and then all the bloody flames of blue sky red sky where they've been dropping around london because it was only about so it was about 14 months have talked about any of that chest long about london okay and to collect the debris from bombs and things that I hit the curb and stopped and paid a bit of school and show them off you know well it's all you knew I guess more time and you were younger all you knew when you were younger and you were younger yeah and all that's immune with gold mhmm okay you yeah what what a gentleman playing some of them as well what's how far do you have in the horizon really in the sky yeah wow incredible I mean you're just reminiscing about second world war but I'm not reminiscing you started it I did start it I asked you it's true yeah we've we've had a chat we've made a plan and we the last thing I should ask you and I talk to all my patients is about resuscitation when you're in hospital mhmm about cardiopulmonary resuscitation I think what we're doing now is the right thing to do giving you lots of active treatment on the ward I think if you were to deteriorate to the. Where your heart were to stop I don't think jumping up and down in your chest would make any difference oh wow to be blunt alright so I don't think that that's the right thing for you I don't think it'll change anything so what do you propose I propose that we fill out a form for when you're in hospital that if you were to deteriorate suddenly on the ward we wouldn't jump up and down in your chest we'd do everything up to that. To what would happen if that were to happen right but if it were to happen yeah I'm not going to there's no sign on your blood test that that's gonna happen all your organs are absolutely fine I was just saying the whole thing well actually for the first time I hadn't taken me atenolol today I haven't seen your blood pressure actually yeah I looked at it even more doctor no I'm sorry I'm sorry I'm sorry great have you had joint new medicines should I write them up for you yeah yeah I'll get them written up for you so you can help them yeah which medicines do you take uretinolol and the other stuff you take at home I've got that at home and we can rust a sub up for you I'm sure if you've not had them this morning it doesn't sound like cow we'll see if we can get you feeling better such that you can have them we were saying I think it's entirely reasonable for him to be in hospital and I'm not trying to get him out of hospital I think if we make you feel better today to the extent to where you eat and drink something and feel like you're able to go home then that would be a great success I think because I think languishing in a hospital bed is not good for people but I think that that we're not that that's what we're aiming for but we may not achieve it and we may stay with him some stuff to look fine we're aiming to make him ventilation yeah I know dave I know but I think if we if we do get him feeling better to the extent where he is able to eat and drink then I don't think keeping him in bed overnight is gonna do him any favors I think it's both to be they have to pay me to come here there's lots of infections coming around and if I were you I would try and get up as soon as possible I think you know what I wouldn't care about having a some things happen overnight yeah and we need to have cultures at home yeah I understand I think we need to be confident that you are eating drinking feeling better and that you felt ready to go home before we did that I think I'm aiming to do that today but I may not achieve it very dramatic yeah that makes sense does that make sense yeah yeah okay great I'll give you a big I'll 1 of the nurses will back come give you a big cocktail of medicines to try and make you up okay thank you but how long does that take to get through the but then 3 hours and 10 minutes is 43 hours max that's the problem the other 1 was on 500 the first 1 that's around $2.50 in hour oh no yeah 2 50 mils an hour yes yeah so yeah the other 1 was on he seemed quite probably a quicker bag yeah a little more yeah yeah like like say your blood tests are fine your kidneys aren't hit with dehydration you are dehydrated by the look of you by the look of your skin and of your mouth yeah sure but your kidneys are doing fine just good about yeah and the electrolytes in your blood are also fine so all bits with excuse me an acute dehydration and not something seriously serious so so this should sort of help okay thank you if you think of any questions I can come back and just ask them okay