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Hi there my name is bora 1 of the doctors and stuff that I'm taking for advice on 1 of our patients of course mate so 35 yep cool is 87 david with jarlotte is that him yeah that's him man cool I don't recognize the name but maybe what's up so basically between okay between 3 iron infusions yeah wow the so 3 total 1 prior to admission mhmm so you've not heard endoscopy acute blood loss yeah and so you've not been like obviously you're not able to maintain maintain his age and his iron because we spoke to renal and they were like unless his iron's above 20 his transferrin status is above 20 you can't give him any epos so it's easier it's a bit of a loose end of what to do next yeah of course it's a significant anemia isn't it and it's it's strange that we haven't come to an underlying cause for it for yeah I mean he's obviously been anemic since january at least yeah and I think like the renal team is saying it's an upper gi bleed and then catherine think it's more renal we're we're sort back in the middle of night know melina would come out yeah if there was an upper gi bleed have we do we think that's what's happening or no no I think he did have an episode earlier on in his admission but he's not been currently since I've been here for the last 2 weeks and his urea is bloody high though isn't it it's been up to 50 and stuff and is it it's kind of I mean his creatinine's been bad as well but yeah it's a bit out of keeping really isn't it his creatinine's 263 and his urea's now like 30 35 but it was 50 yeah back at the november he's a poorly man isn't he yeah and has he had a pr exam is to look for melina not recently yeah fine I mean I think that's a reasonable thing to do isn't it if he's got nelena then that then that seals the deal but but if you think he's not fit enough is he fit enough for an endoscopy or or no that's the thing really because we were sort of on our notes he's been saying that he's not for ogd and then we're looking through it and it was like not for ogd unless he's an acute bleed so if he's fit enough it's it's hard to say because he is a very poorly man yes the next thing that'll be happening is like we're going to all switch him and send him home and looking at like his homemade oil switch he's probably not gonna come back but it's not looking like a good no it's not looking like a good outcome I guess in the he's 87 he's got a terrible heart so yeah but yeah so I mean it certainly biochemically I wouldn't I would believe that he's if you told me he was bleeding I'd believe you looking at his biochemistry his urea is high yeah his hemoglobin's dropping despite huge amount of iron supplementation yeah he's hemodynamically okay but you can have slow oozy bleeds I mean whether it's coming from you know an area above the dj flexure you know that will respond to an ogd is is obviously unknown but we could we could ascertain that is he on oxygen no he's not no he's not fine and his but everything else is okay so and he has why is he here because of overload not because of an mi yeah so primary complaint is overload yeah fine okay and he's obviously he's moderately reduced reduced ejection fraction yeah and but to be fair I mean his I mean his echo is not terrible is it yeah no and there's a weird situation there because previously his prior echo to that was a lot worse than the current 1 so that's also a bit of a mystery that is a mystery and you don't think he's had a heart attack just because that would increase his risk around ogd quite considerably yeah not during this admission yeah there wasn't a reason for his like currently but he's had an n nstemi in '24 nstemi 2024 fine okay yeah that was a while ago fine and he's also on warfarin for a metallic abr fine and that doesn't help does it no and his inr has been in range fine yeah yeah it's challenging isn't it whether he's got a slow ooze from somewhere and then thinking about you know we could do an endoscopy fine is he on any ppi we tried that sure yeah so let's have a quick check oh let me I don't think so I would say that's the old child because that's what will really make the difference to him not looking with the camera if he's got an ulcer that's bleeding then that'll probably be the treatment of choice for him really yeah and obviously an egd is gonna be high risk his heart rate's gonna go up to a 120 130 he's gonna have an element of myocardial ischemia when you drive his heart that fast with a camera down his throat yeah and so you know there's something to be said for smashing him with loads of ppi and seeing what happens sorry 1 second it's all good yeah you're on famotidine famotidine so an h 2 receptor antagonist yeah but no not omeprazole and lansoprazole no omeprazole and you said he's on warfarin he's on antiplatelets he's on aspirin probably surely sorry I didn't catch that last bit then so probably he's on aspirin surely no he's not on aspirin nor is he on cloppy or any anticoagulants no okay fine that's helpful yeah I'd well I wonder why he's on famotidine then and not ppi yeah I can definitely ask yeah see but I mean I don't understand why you would I mean sometimes people are intolerant sometimes people have hyponatremia or hypomagnesemia and it stopped there can be lots of reasons I can't get on his gp record unfortunately so I can't work out whether he was on it before but I think for him entirely reasonable thing to do to try putting him on loads of ppi ppi he should have a pr exam if he's got molina then he should be referred for an ogd and we should have a look shouldn't we yeah but if not I would think maybe we stopped it because his mag was been mag was naught 0.21 in september so that could easily be why couldn't it yeah but if he's the possibility of bleeding now I think it's not I think it I would try giving him the omeprazole again rechecking his magnesium tomorrow and see if he needs replacement and then the other question I guess is about hemolysis could he be lysing I think we had the studies done it showed no hemolysis yeah fine was thinking it was just coming off the valve but I think it's in the blood results there currently no it's fine so ldh was high ish reticulocytes were high ish but only just above the normal range for both of them has he had a direct coombs test like a to see whether he's lysing well he really should get jaundice but we've not checked his liver function in a while oh no we have back in the sixteenth his jaundice wasn't on december 16 but then he went back to normal again really weird why don't you do a a a direct anti antithrombin a coombs test and see whether he's lysing that would be the best test for it I can't see that you've done that and if he's if he's got hemolysis then that through the valve then that would make sense but no doubt this is going to be a multifactorial anemia with possibility of bleed which we're going to explore with the pr and we're going to treat with some omeprazole anemia of chronic disease and a an element of hemolysis probably driving a lot of this yeah so that sounds good what do you wanna do about the light the hemolysis there's not really amount huge amount you can do through a metallic valve no not really much you can do but cool we've got a plan haven't we do a pr if there's no need to refer him for an agd start him on some omeprazole if your if your team are happy with that and hold fast great sound good I can just get you a last name my name is rob miller thank you very much for the help there no worries have a good rest of your day cheers mate you too bye bye bye so that's david jarlett 470635

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Medical ST5 Miller Clerking
[Current Date] [Current Time]

Presenting Complaint:
[The reason for attendance in 1-3 words]

History of Presenting Complaint:
[Chronological narrative of current illness using short, clear sentences. Include:
- Onset, character, location, radiation, timing, exacerbating/relieving factors
- Associated symptoms
- Impact on daily activities
- Previous similar episodes
- Relevant collateral history from relatives/carers
- Any relevant background from other healthcare professionals
Do not repeat patient's name throughout. Be concise and tell a chronological story to the reader. Do not include subjective descriptions of the symptoms e.g. "severe" or use unnecessarily long words.]

Past Medical History:
[Bulleted list of significant medical conditions with relevant details:]
• [Condition with year if mentioned]
• Diabetes mellitus - latest HbA1c: [value] mmol/mol ([date])
• Asthma/COPD - latest spirometry: FEV1 [value], FVC [value] ([date])
• [Previous surgeries with dates]
• [Other significant medical history]

Drug History:
• [Drug name] [dose][units] [route] [frequency]
• [Example: Omeprazole 20mg PO OD]
• [Example: Clopidogrel 75mg PO OD]

Recently Stopped Medications: [If relevant]
• [Medication] - stopped [date/reason]

Allergy History:
[If allergies mentioned:]
• [Allergen] - [Reaction type] ([severity if mentioned])
• NKDA [if no known drug allergies stated]

Social History:
[Living situation. Who they live with, housing type, if mentioned]
[Mobility. Walking aids, stairs, transfers, if mentioned]
[Carers. Formal/informal care arrangements, if mentioned]
[Occupation. Current/previous if relevant, if mentioned]
[Smoking. Never/Ex-smoker/Current - pack years if mentioned]
[Alcohol. Units per week/Never/Ex-drinker - if mentioned]
[Functional Status: Impact on activities of daily living, if mentioned]

On Examination:
[General Appearance. Alert, well/unwell, distressed, if mentioned]
Observations:: [If mentioned - HR, BP, Temp, RR, O2 sats (do not use subscripts)]
• Abdomen: [Inspection, palpation, percussion, auscultation findings. If not commented upon, document as normal]
• Cardiovascular: [Heart sounds, murmurs, peripheral pulses, oedema. If not commented upon, document as normal]
• Respiratory: [Chest expansion, percussion, auscultation. If not commented upon, document as normal]
• Neurological: [If examined.]
• Other: [Any other relevant examination findings, if mentioned]

Investigations:
• [Test name] ([date, if mentioned, do not include include today's date on results, list without a date]): [Result without units]
• [Example: Hb 85]
• [Imaging type] ([date, if mentioned]): [Key findings]
• [Example: CT Abdomen/Pelvis (15/03/24): Sigmoid diverticulosis, no perforation]

Impression:
[Main diagnosis]
Differential Diagnoses: [Only if multiple possibilities discussed]
[Secondary issues. Relevant comorbidities affecting management. If mentioned]

Management Plan:
1. [A numbered list documenting the management plan to be undertaken, if mentioned, include:
- Immediate management/monitoring,
- Investigation requests,
- Treatment interventions - medications, procedures,
- Discharge planning/follow-up arrangements,
- Patient education/lifestyle advice,
- Referrals to other specialties if needed,
- Which ward or specialty the patient would be best admitted to e.g. "Respiratory Bed",
- Escalation plan that was discussed - whether the patient is suitable for CPR, ITU and/or NIV.]

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