Brian palk p a l k 210999 77 year old man past medical history type 2 diabetes atrial fibrillation wimmer cell carcinoma of the tongue 2016 treated with operative management + chemotherapy and radiotherapy and he also had a peg cited during this time medications there's betamethasone cream bisoprolol doxazan levothyroxine investigations qfit 90 micrograms per gram that's 9 0 hemoglobin a 105 with mcv 66.8 so I'm upset his neck back against his older blood tests hemoglobin was a 147 back at the 2024 with an mcv of 85 at that time mister brian powell please I'm 1 of the mcs yep I'm ralph I'm 1 of the gastroenterology registrars nice to meet you nice to I'm okay good I'm glad what's your understanding of coming to our iron deficiency anemia clinic I'm assuming because the diet's all over the place where it kick off fair enough and tell me about is down to that stool yeah waiting to get my teeth sorted teeth sorted I heard yeah so I'm on a pasta diet and a pasta diet and a pasta diet oh so being you know pasta's nice but it's not that nice is it well exactly just wanted to chew and just wanted to swallow a bit how long did you know I've been cramped for have you been on the past before for quite a while quite a while yeah mhmm and I suspect that's why I'm like am why I'm here mhmm because I I just get tired mhmm and I'm working are you what do you do for a living I'm in the flooring business mhmm used to do a lot of work at this hospital fine really well they are lovely floors so thank you before you were born actually yeah long time ago I love that so what kind of my own business so you know mhmm so I work 4 days a week so I'm I'm ongoing all the time I'm being mobile it's just that if I if I'm doing nothing I'm knackered you know like I do not go to bed it's not like me I'm not no I don't do that and looking at your blood test I could see why you might be exhausted because you're you become quite anemic yes and you've got low iron levels in your blood and it could be dietary certainly looking back the last time we measured it was back in 2024 at that time right it was normal we had normal iron levels of normal blood counts then sometime between then and now your blood counts have dropped off yeah in a a picture consistent with iron deficiency thinners there as well yeah I saw when did you start the blood thinners the doxplan isn't it years ago 2 years ago but yeah it's pretty irregular heartbeat you have atrial fibrillation stuff yeah I don't to be honest I'm not quite well you know I had the old head and neck joggy I heard which I you know I got through that alright worked all the time did you well fine and you have an operation on your tongue right and then you have chemo radiotherapy yeah I mean not me for sex got that but I work way through it mhmm because I went to see consultant and he said what do you do brian I said this is a little flaw in this I said yes I will I said I've got to mate yeah because I've got fitters that rely on me of course so I said if I'm gonna I had 35 radiotherapy I said if I can have it at the end of every day I get a chance to work for it oh and it messed me up for a couple of days off and on then the chemo suddenly just burst out and all these bloody bumps and all my legs but I can honestly say in all the it never nothing hurt good nothing really hurt recovery but that wasn't painful it was you know mhmm it's what it is isn't it and I'm I'm fine good you know I'm fine I'm glad yeah I'm fine and how's your weight it's stable I think and the because I'm not eating that much I'm not having the right food probably and how long has it been now with the bad with your teeth not right you've been seeing restorative dentistry you started seeing them 12 months ago yeah about a year ago and it's still not sorted they messed me out for a while sorry and now you know I I was here last week he said I'm gonna get you sorted by the january I thought well I'll bloody hope so because there's nothing worse of course nothing until you horrible alright so what do you have on your pasta sorry what do you have in your pasta tuna mhmm that's got lots of wine in it yeah tuna and and lasagna mhmm things like that so do you eat fruit I I enjoy that I've got a healthy appetite good a couple of things I'm struggling to eat the swallowing is brilliant mhmm it's gonna help course so you know you you tend to when I say to my dear lady I need sloppy foods I'm not going to chew too much you know so I can't have a a steak well I wouldn't have a steak anyway because she's vegetarian so that knocks out on the head fine don't eat anything that said her face or parents by the way think about that do you think about that 1 yeah fine you think about that a muscle you can should you have a muscle couldn't you is it girl just a muscle muscles muscles yeah no I was not into fish stuff really okay that's tough as well because they don't have a face and then you'd you'd struggle to find their parents yeah but not bat off the table as well why do you have any vitamin c in your diet do you eat oranges or take vitamin c supplement or drink orange juice I'm I'm just spinning I I don't and I will to be honest jan said to me he said I've got some lovely oranges I said well okay let's have an origin there that's me the tuna's got a lot of iron in it so if you're having a bit of that they should be sufficient to keep your iron levels up when people develop iron deficiency we worry about something bleeding slowly in the gastrointestinal tract I had black poop did you 1 just black yeah really black but it was a 1 off right and when was that that was month and and did your gp start you on anything when you had your jet black poop well I I I had to give a a sample that yeah that came back with a bit of blood in it bit of blood in it apparently mhmm but I've never seen any sign of blood it's microscopic blood this is what we're looking for so we're seeing microscopic drops of blood in the poo mixed in together yeah right and that can be from lots of things right it can be from fleshy outgrowths in the bowel which bleeds slowly which we call polyps yeah yeah it could be from benign things like blood vessels that are close to the surface yeah it can be from cancer right yeah and that's the main reason we want and to if you're working you're pretty fit I am pretty fit to be fair yeah and the best tests we have to exclude cancers in the bowel are camera tests endoscopy and that's 2 camera tests what we'd recommend a look up the bum yeah and a look down the throat right to look for anything worrying or sinister and the good thing about the camera test is it also tells us about benign causes like right blood vessels that are close to the surface and things like that the camera test in the top half is very easy to do it takes about 10 minutes and you just need to starve for the for the 6 hours before that test yeah the camera test in the lower part is a bit more involved yeah sure you need to have the bowel preparation before that and you need to eat a change to your diet a low residue diet that we call it your pasta diet should be sufficient for that and we we recommend that for the few days before we'll send you lots of information about it right before you have the test then you also as well as the change to the diet need to have bowel preparation yeah which is 2 l or so drinks of strong laxative medicine which empties you out completely yeah right and you'll go to the toilet 6 8 10 times after that water will come out right and then you'll be ready for us to do all the tests so that everything's nice and clean okay so it's a bit involved it's a bit invasive same thing yeah but it does give us the best view of what's going on and it lets us exclude anything worrying or serious of course what do you think about that it is worries isn't it yeah yeah it is it is worries yeah fair enough yeah so should we do that for you yeah yeah lovely we can do them both in the same city we can do them both at the same time oh that sounds good come in yeah to our endoscopy room we'll do 1 and we'll do the other immediately after got it if that's okay yeah so you wouldn't have to have too much time off work yeah you may find the bowel preparation and working quite challenging yeah I'm sure no mean take a bucket so yeah exactly yeah take a bucket or take it yeah exactly fortunately I've got a loo right next door to me that's very good yeah fine we'll take you can take it in the evening if we book you for the afternoon slot so you'll just need the 1 day off that kind of thing is what we'd recommend anyway the other thing that makes us want to look at your lower bowel as well as the iron deficiency is the blood in your stools there's a chance of something we see that something's bleeding because there's blood in your poo right and we see the effect on your blood counts because your iron levels are low right have you has your gp started you any iron supplementation any iron tablets would you like that just taking some from oh maybe barrett just started taking some from yeah fine which 1 are you taking oh god don't ask me it's a life of my decision yeah the iron tablets things like iron iron floridix or iron puffers floridix yeah it's got not very much iron in it no that's all I thought yeah it's it's got some don't get me wrong it's got some but it's got about 10 mg of iron in which is a good good if you're not losing blood that will top you up just fine but if you are losing a bit of blood which we worry you might be you you're losing a bit more will I not see evidence of that somewhere so if it's mixed in with the stool you might not see it and the fact that your body's digested it a bit but will I see it in the stool itself well you might not because it because as we as your body digests blood it turns from red to black right so it can be mixed but I've never seen any black and since after that 1 time just once no 1 off yeah it it can be that it's because the blood is mixed with the stool so well these tiny flecks of plaque I just don't see but your test does confidently show that you've got blood in your poop it's a very good test and it has shown that so think we can be quite confident that you've got some small microscopic drops of blood in there and we're talking about tiny amounts 90 micrograms of blood for every gram still but the gp mentioned the old c word do you think well that's what I'm here to exclude that's why we brought you here quickly and we'll do the tests really quickly yeah yeah your the pattern on your blood tests it it's not incredibly worrying to me right you don't have any of the other markers on your tests of something sinister or worrying but your risk is about 10% right with iron deficiency right if you submitted this blood this stool test to the bowel cancer screening program yeah it you'd come back as normal right so that's the other alternative thing right if you didn't have iron deficiency we would ignore that test right with 90 of blood in it I guess we'd say you don't have any symptoms you're fine yeah your carcot off is 120 for that does that kinda make sense yeah yeah so some iron supplements do you mind if I prescribe you some absolutely it's good I think I'll make you feel better yeah in terms of if you've been feeling a bit fatigued I'll prescribe you a course of 3 months right and that's what we usually recommend taking iron supplements for we don't find anything with our tests then take it for 3 months top up your dietary stores yeah and then stop taking them and then we'll assess again I don't know and if you become more iron deficient again then we can talk about yeah some more fun tests to do 6 think we've got a sticker here good any questions anything I've forgotten like a fever I I feel okay you know it's weird I just get a bit tired yeah I suppose that's the age a bit as well look at me wrong I'm aware of that return well I think a lot of your tiredness will be driven by these low iron counts and being anemic it doesn't it makes you feel bad yeah yeah do you mind if I ask you to have some blood tests today is that okay yeah that's fine yeah thank you we can do them here just to make sure you haven't got celiac disease because that's easy to cause and it can cause iron deficiency yeah recheck your full blood count as well as look for urea wonderful and that's as well good do you and you eat oh you're eating pasta so of course you're eating gluten just a test is only good if you're eating gluten but you are because you're on your pasta diet which is entirely gluten alright that's good great that's your prescription which you'd get from the hospital party oh is that your sticker can I borrow it for you yeah yeah thank you very much I say borrow it because you're not getting it back where I get you staying at the pharmacy down to the pharmacy in the hospital exactly and I'll show you where the blood tests are alright miss pobb lovely thank you is your your flooring business named after you is it pobb flooring I'm classic floors classic flooring there you go and you went to go if I had any yes been near a long time I know I'm not gonna show you I'm show you my blood test so nice to meet you mister paul your blood test so plan bidirectional endoscopy blood testing including ferritin and transferrin saturation iron supplementation right with the results on examination height 7 171.5 cm in weight 77.7 kg giving a bmi of 26.4 dear gp had the pleasure of meeting mister polk in iron deficiency anemia today on behalf of doctor powers the concentration was face to face full stop <\n\n> He has been developing an iron deficiency anemia sometime over the last year with evidence of microcytosis and anemia on his last blood test in november but I note that his blood tests in 2024 were normal showing no evidence of iron deficiency at that time over the last few months he has been feeling more fatigued and tired and he has had a single episode of jet black tarry stool 1 month ago of note he's been on edoxaban for atrial fibrillation since april 2023 he's been struggling with his teeth lately as he is a survivor of tongue cancer and has been seeing the restorative dentistry team for the last 12 months or so trying to improve his dentition and his ability to eat he's currently on an entirely pasta diet but he does have tuna with his pasta as well as has lasagnas and so I think his dietary intake of iron should be sufficient his weight is stable <\n\n> In terms of his life more generally he's working in 4 days a week with his flooring business and he lives with his wife his who performance status is 0 <\n\n> We discussed today that his blood tests do certainly paint a picture of iron deficiency and his stool test has demonstrated microscopic blood in the stool in addition his single episode of jet black tarry stool does make us worried about bleeding within the gastrointestinal tract as a cause for his symptoms and he would be fit enough to undergo bidirectional endoscopy to investigate this in more detail he'd be happy to have this done and we briefly discussed the tests today as well as the preparation for them I look forward to seeing the results of his endoscopies and I note that he'll need to stop his edoxaban prior to our tests I've given him a 3 month course of iron supplementation today in action