Linda carras 243904 referred for the gp for changing bowel habit constipation no weight loss no prp microcytic anemia q fit 330 past medical history focal onset epileptic seizure february 2025 hypertension steatotic liver disease pulmonary embolism 2014 breast cancer 2013 treated with wide load excision chemo radiotherapy ibs ckd 3 asthma medications list nustendi 180 by 10 mg tablets 1 to be taken once a day lamotrigine 75 mg twice a day losartan benzodiazide and omeprazole 20 mg twice a day apixaban leuphorbeck inhaler 75 year old lady investigations fit 30 micrograms blood per gram stool ferritin 21 full blood count hemoglobin a 116 with mcv 74 note hemoglobin a 127 with mcv 80.3 in february 2025 and with persistently raised platelets of 540 on most recent blood tests looking back at older blood tests hemoglobin was normal back in 2024 and platelets were normal on the high higher end of normal throughout but were normal back in 2024 linda carras speaking hello I'm rob my husband please the more merrier I'm rob 1 of the gastroenterology registrars nice to meet you both mister carras hello hi hi miss caris nice to meet you come on in have a seat cheers good yeah very light really take this 1 for me I can see the screen it's appreciated but oh if you got your sticker on please forget I'll take that from you thank you very much that's fine how are you well it's been a bit of a tough time really I'm sorry no but I've had breast cancer and I had a bit of trouble I had a bit of pain and what have you so they took me in luckily everything's alright so that was 1 thing and then I had an appointment to come here they did a couple of blood tests at the surgery and the first 2 seemed alright and then they called me in again and had a phone call to say that I'd got a bit of blood in this I haven't really been right since covid the first time since what 2020 yeah the first 1 you've had covid twice at least twice yeah what's changed since 2020 then my appetite has gone right down I reacted to both the flu jab and the covid jab so I had to get over that and then we got it and the same thing happened it really upsets my stomach sets your stomach in what well just really I felt a bit sick and under the weather and as if I got a cold or a yeah you know or something this is when you had covid yeah and then between those episodes did you feel back to normal or not really no not really it affected my stomach a little bit mhmm to be honest we we the 3 of us in the house and we we all seem to get healed together and I I haven't been right since we last had covid no and we just had another injection I talked to the doctor about it and I understand that yeah but you've asked the question no of course and then possibly 2 months ago yeah my husband said I'm I'm going to cut out you know things and cakes biscuits and what have you to lose weight and I thought well I'd better do the same really and I started to lose weight since then and I think I was 13.3 something like that because I used to go to the lymphedema clinic for my legs and they used to weigh me each time and so the last time I can remember I was about 13.3 pounds well since then I've gone down to whatever that is 18.3 pounds I'll have to convert that into old money 12.5 pounds at home I I weighed myself before I had my shower so I got nothing on mhmm and yesterday I weighed myself and I was 12 7 12 7 yeah yeah but here slightly shoes on and things well I took my bits off but because I wanted to do my height as well yeah so I've lost a bit of weight you're meaning to but it's bit off but it's far quicker than you anticipated is that fair to say I seem to lose like a pound every week or so I can't think now but yes I've gone down to that and I'm just very tired all the time and feeling a bit weak but then a lot of my tablets have either changed or I've got a glioma as well what do you call it it hasn't grown at all I'm waiting for another mri scan but you see I think those tablets make me feel a bit they're pneumococcal yes they make me feel funny so they did put me up and that's what led to you having the seizure in was it in well I february or something I seem to remember I don't think it was a seizure it's not a seizure no but is that highly controversial february 25 being in I was out shopping with my daughter and I started to feel a bit funny and then I had to lean over the trolley and they finally got me a chair to sit on and my daughter says I was unresponsive because I know I could hear everything that was going on I just didn't want to talk to anybody you were deliberately unresponsive yes but she says I was deathly white anyway they brought me here eventually and they gave me all sorts of different tests blood tests my blood pressure was quite high but they thought that my blood pressure had gone too low so they thought it was tapping kinked with everything and then you had a scan of your head which has identified this glia more before knew yes but we feel that down in a and e they had to put something down on the floor oh you're right I do a e they said that she'd had a seizure and because of that she stopped driving she's on this ratchet drug which doesn't seem to be doing her any good at all they've also changed other drugs they took me off I can't remember now took me off a couple of tablets because they said I had too much calcium in my blood and I came off I can't remember I've had so many different names they took me off the drug I was having for my oestrogen you were on hrt were you no no no no it was a suppressant oh I see your tamoxifen or letrozole you were on that's something like that it was hydrozole at the end it made me very nervous because I thought I have gone without it then I think I started to feel ill not because of that but because they kept changing all my tablets of course as doctors and changing tablets feel terrible love it we're getting back to this seizure business a few weeks ago we had the telephone good with a neurologist with neurologist brilliant in accident I think it was and I listened to my half of the conversation at home and when lindy finished talking to him I spoke with him and we talked about the seizure that did or didn't happen and the consequences of them putting seizure down in that's her significant yeah agreed I said look it stopped her from driving and he said well who told you that anyway to cut it short because you're busy at the end of the conversation he said to me well if you want me to take her off this drug I'll take her off it yeah that's what I was gonna say as well let's come off it I'll try coming off it he said talk to the dbna you and I I just believe it mhmm but this is all down to what a and e put down ms reggie for me they put me on something else first they put me on something else which I can't remember the name of and really didn't suit me at all which is why they put me on the loxapine what did I say now so the neurologist is going to take you off it or what's your plan you left it with me oh fine I'm due another mri this month but I haven't heard anything yet because it's usually the guy from plymouth the consultant from plymouth that organizes that but it's very difficult to get through to them or him I can't speak to him because the receptionist or the secretary and I phoned after I'd had this episode I thought that'll let him know that I've had whatever and I said can you pass the message on I sent an email I think and then she phoned me and she didn't pass it on I didn't hear from them again and I didn't hear anything from her I don't think it's grown since they first started my mri and he did say at 1. That I could have been born with it so who knows certainly some of your symptoms in terms of the fatigue that you're describing could be driven by these low blood counts yes on on your tests so I mean was it very low then it's not very low but any amount of anaemia in a normal fit and healthy person can make you feel tired and crap jeremy and back in february it was all normal and then in november you've had 2 blood tests sequentially that have had low iron low blood counts in a pattern consistent with low iron levels and you've had some confirmatory testing which shows you a lot of you see they told me I wasn't anaemic at first and they said that my iron was okay didn't they didn't they which I couldn't understand and then they said that can't kaldivisi remember anaemia is challenging yes we specialise in it so it's what may appear to some people as not iron deficiency looks like iron deficiency to us and vice versa okay as and they said that to me this looks very much like iron deficiency although your ferritin the measure of iron in the blood is technically normal the pattern on the blood counts makes it look very much like iron deficiency and my problem was iron you put me on iron tablets for few I'm just wondering whether did you have any tests to look for why you were iron deficient had an oral interesting because it was due to your tablets that you were taking yeah were looking for cancer all over the place with me and that's kind of what you're here with me to talk about as well we know that iron deficiency anaemia carries a risk of gastrointestinal cancer associated that with risk is difficult to quantify but for you it's somewhere around 10% so it's not an insignificant risk of something worrying going on however 90% of people in your position won't have anything worrying mean on occasion I mean this is over five-ten years every now and again I get this feeling here that it feels as I've been punched in the stomach and then I'm most often sick and I empty myself out as well at the same time which first of all I always think oh is it something I've eaten and then I have been known to have ibs down here don't know various old places I and what are your bowels like at the moment do you do you open your bowels every day every other day oh yes every day twice a day depending on what I've eaten and how much and and normal form stool comes out it seems to be lovely I I have had the odd occasion where it's been but then this you have got quite a delicate stomach yeah lamotrigine I've put on it warns that you might be constipated or have diarrhoea which I have had so I don't really think much about it but it was when they phoned to say that they'd found this spot of blood and if you had no symptoms at all and you didn't have iron deficiency this test would be normal right so if you were submitting the same test for bowel cancer screening level the cutoff level will be 120 and yours is 30 and normal is less than 10 so if you have no symptoms and you're in the screening programme we would say you're normal but the fact that you're iron deficient makes us look a bit closer right well I had to like the ordinary bowel test that they send you through the face and then I had 1 recently that they had to send away and that's what showed up yeah exactly as I've said I think there is that risk of gastrointestinal malignancy with this and I would suggest we investigate it it sounds like you're a fit independent healthy person and it sounds like we should investigate and do the best tests that we have to look for that and that's endoscopies they're invasive tests not the most is that down both yeah okay but we know that they have the highest pick up rate to detect concerning things and it also detects non concerning things right I would have the 1 up when did you have the 1 up god because I couldn't see that you had the time ago fine yeah decade ago and I've had investigation done as well got them down because 2 they thousand 9 they numbed everything which was normal fine mhmm yes I don't like that 1 so much oh I'm sorry they are the best tests to look for I mean is there any any chance of having this 1 done without without the spray yeah well under anesthetic under anesthetic we did you have it under sedation last time or just with the spray just with the spray at my nose and because it went down into my throat and I couldn't I couldn't swallow oh it was a transnasal endoscopy yes and and yeah of course it was horrible I I I was felt as though I was drowning you know I'm sorry yeah we you can certainly have it without spray if you want that's absolutely fine we would usually recommend sedation if we're doing both tests so you'd be quite sleepy and probably wouldn't remember them it's kind what we'd aim for okay well I I said that I wasn't gonna have anything when I had mine done and I regretted it yeah I think I'd rather that more is more is what I say yeah well that last time we we we obviously you had some sedation last time yeah and up the nose but not for the other thing oh with your colonoscopy did oh did I you did you had some nausea and some fentanyl because he don't remember it was it's the idea oh right because he he actually showed me on the monitor after he had a look so yeah yeah so what that's what I would recommend is a fibrotic endoscopy right do that within the next 2 weeks to exclude a worrying cause for this mhmm if that's if you're happy to have that I think that's all anything to rule out I think that would be that would be what I would have in your position I think so can you just repeat can I put this how bad her results were the test test the bloods your hemoglobin for 1 to the mhmm so normal is a 120 and yours are a 114 a 116 so only just under the line yeah and we looked at the graph you know back in march you were in the green a 127 and then you just dribbled up beneath it but with the eye of faith your blood cells have been small for some time so you've probably been iron deficient right for most of 2025 okay and looking back at your blood tests on our old computer system your blood cells were a much better size back in the 2024 so it's likely that something's been happening over the last year or so because back then your blood counts were your blood cells were a good size right nice cream size yeah and and you had normal blood counts so you had good amount of cells and they were all very nice looking and good chunky full of iron whereas now you don't have very many and for all of 2025 you've had not enough iron no you've had bad eye problems extremely ill because of iron deficiency would say it could well account for a lot of iron yeah certainly makes you feel crap oh dear yes you haven't been tested for coeliac disease which is a very simple easy thing which can cause iron deficiency and doesn't require us to give oral tests sister had crohn's disease and diverticulitis and ibs oh my goodness it's sort of all bowly isn't it yeah it is the good thing about these the invasive tests is that they look for other things like crohn's disease that can cause iron deficiency although it seems unlikely that you develop it at this stage in life right no because she was what 18 20 something like that mhmm yeah and do you eat gluten wheat I I do lovely I've gone on to sort of seeded 1 you know that kind of thing that's good great so there's we can take some blood tests today to make sure you haven't got celiac disease I'll book you the 2 tests within the next 2 weeks I'll write you with the results of them when they come back right so are are the 2 tests done separately or well we could do them at the same time if that's alright yeah we just do them at the same room at the same time you come in and we need to get it out of way in alright yeah so I'll put this for you and then the last thing is about iron replacement right has your gp put you on any iron replacement any iron tablets would you like stuff might make you feel better well we'll have a go and see what happens because they can make you a bit constipated they can it's true they can we've got lots of preparations and it's usually not the iron that makes you that bums up your bowels it's what the iron is bound to right so if you have a problem with 1 preparation try another and we've got lots of preparations there you we can usually find 1 that works right okay the other thing is that sometimes excess iron can do the same can cause the symptoms I you're eating more than your body can absorb and then the iron staying in your gut is what causes symptoms right so if you're getting unpleasant bowel symptoms with this try taking it every other day instead of once a day and if you're still getting symptoms with that then get in contact with me and I can send you a different preparation that alright yes fine lovely and can I do I have to get this at the you do at the hospital pharmacy oh right so okay sorry I don't have green ones like gps do that you can take anyway it's the were you going to have something to say about the drug that they put them on for the lamotrigine mhmm well I think if the evidence of seizure is not that high seems pragmatic that you could stop taking it and if you don't if you deny that you've ever had a seizure you didn't feel like you had 1 and you and if you don't find the medicines making you feel very good it wouldn't be an unreasonable thing to do to stop it the worst thing to happen would be to you to have a seizure which would obviously put you back quite significantly because if did have a seizure and then obviously you'd be back to not driving again etcetera etcetera so it's all about that balance that's a very personal decision to have I think probably a lot of harm being done simply by the fact that she's taking the bloody thing which makes her think that she is susceptible if you get my meaning no completely understandable I think obviously we've had some time to talk and obviously it's face to face as opposed to all the telephone so it's maybe easier to understand but I think that's what the neurologist was trying to explain from what I understand from you is that it's a very personal decision and it's about and it's you you know from our from our perspective we put you on the drug and just forget about it because it's easy for us I don't have to take it every day I don't have to deal with side effects and it makes me sleep soundly in my bed thinking that you won't have a seizure yeah but it's very selfish and it's all about you and what you want to do and I think you should feel empowered to do whatever you want to do with your health and I think us as doctors our job is the to you a first consultant I've never met him it was all done by phone thank you it was from plymouth and then after I'd had this do in sainsbury's I saw somebody here and he was the 1 who said all that about the driving I think it's best for dopton to be honest think that's entirely reasonable make a decision think I ought to first of decrease what I'm having should we not have it straight yeah a 175 in the morning and a 175 mils in the in the evening serotonin sensation so if I dropped off the 2 20 fives mhmm down to 50 morning and 50 evening because you can't just suddenly stop it suggests to taper off over 2 I'm not a neurologist so I only prescribe this medicine but it says to taper off over 2 weeks or longer on our computer system so perhaps you could say 4 weeks is longer than 2 weeks isn't it make you feel quite good about tapering down over the course of a month I think the incisions are going to do if you want to put it on the calendar yeah and say I've stopped it at this? I'll stick to it yeah but obviously if you had a seizure when you're driving it'd be a catastrophe exactly both for you and potentially someone this is what frightens me I don't know to no so if you come off it 1 should you should you know it'd be another reason not to drive I don't know yes you know there's no ddla guidance to say you can't drive you know if you've not had a seizure for 6 months or a year depending on the type of seizure you have and the medicine that you're on then you can usually drive again it obviously you're very close to that now aren't you yes if you've been coming off for a year to be able to drive again in february if you're seizure free yeah and it'd be obviously annoying to put yourself back if you had a further seizure but at the same time if the meds make me feel quiet then stop and I think it's a very personal personal decision for you mhmm I mean I don't sleep very well anyway but I just feel tired all the time well I think if I'm feeling tired all the time probably that's probably the high end of this isn't it yeah right okay so blood test today iron tablets to start every day or every other day 2 endoscopies we'll see you there okay so I've done blood tests I'll show you where yeah okay sound good yes we'll sync things well is this was that there well anywhere's fine it's all good the best way in the room is very messed up isn't it good to meet you nice to meet you thank you miss sarah meet that thank you for that yeah and then go all the way down to the blue cabinet just just right at the cabinet and they'll be able to we can seal it there we go so plan upper and lower gi endoscopy number 2 iron replacement number 3 right with results but no follow-up planned dear gp I have the pleasure of meeting missus caris in iron deficiency anemia clinic today on behalf of doctor poles the consultation was face to face and she's accompanied by her husband I'm sorry to hear that she's been feeling fatigued for several months now she hasn't noticed any gi symptoms which is obviously reassuring although she has had some slightly decreased appetite since 2020 2 months ago she cuts out cakes and biscuits and has been losing weight since then she's losing about a pound a week intentionally but it is coming off a bit quicker than she thought it would she's been feeling weak and tired all the time we had a long discussion about her presentation in february where she was diagnosed with having a seizure but she vehemently denies this she started on lamotrigine and she attributes a lot of her symptoms to that I explained that a lot it could be due to lamotrigine symptoms but it could also be that she's iron deficient her blood tests show a pattern of iron deficiency which has been developing over the last year and I know that her platelets are gradually increasing as well her bowel habits normal passing a type 4 stool once to twice per day <\n\n> He discussed today that her blood tests carry a risk of gastrointestinal malignancy of approximately 10% and I'd suggest investigation of this with bidirectional endoscopy she'd be happy to undergo this and would be fit enough to have the preparation I've requested this for her today and look forward to seeing the results I've also prescribed some iron replacement which I hope will wake her feel better height's 162 cm weight is 80.35 kg and bmi 30.2 you're all sincere