The next patient is deborah stanton 271034 51 year old lady so past medical history asthma and stemi discharge on 12/20/2025 medications list aspirin clopidogrel cetirizine montelukast simcor fluvastatin ramipril lansoprazole bisoprolol ventolin terbinafine omeprazole metazone gtn spray nicorette inhalator nicorette patch investigations ogd december 2025 for iron deficiency as an impatient mild patchy erythema in the stomach no significant abnormality of course of symptoms seen d 2 biopsies taken but awaited looking at bloods low ferritin 20 18 the most recent blood test 12/30/2025 hemoglobin of a 110 when was 90 at its lowest during admission december 2025 with microcytosis ttg negative december 2025 ct abdomen and pelvis december 2025 normal intra abdominal appearances infective right lung based changes so hematinics december 2025 ferritin of 23 folate normal b 12 normal transferrin saturation 2% transferrin level 3.1 looking back at other blood tests hemoglobin was a 145 back in 2020 and then most recent blood tests following that hemoglobin was falling to 20 22 in 2022 23 then in 2024 hemoglobin was a 100 and oh no we're not tested but hemoglobin a 124 in october 2022 from previously a 140 something mcv dropping at that time as well so it appears that iron deficiency has been developing since about 2020 to 2022 deborah stanton hi nice to meet you how are you fine thank you I'm gonna do a seat please just tell me what you've had think it sounds like you've had a bad december say the least yeah fair poor thing so you're in hospital from december we got you out for christmas by the looks of it yeah so that's good yeah yeah and how's it been since I know I was supposed to go out 3 days after the procedure but I got a chest infection and then found out my iron levels kept dropping and dropping and dropping was annoyed so I had the camera I had the ct yep didn't show anything worrying so that's good yeah simon later oh yeah he could be bleeding internally pardon I was like what mhmm so yeah scary stuff but yeah but so you're here today to I guess talk a bit about that about the aloe iron levels and work out what we're gonna do about that moving forward have you had any symptoms of change in your bowels or noticed any bleeding from anywhere nothing like that no asked me all that oh so he's not really noticed anything that's good nice but then when I had the camera down mhmm consultant that done it he said to me that he looked back at previous blood tests yeah over the years and he said that your iron levels were low been low for a while then yeah and what couldn't understand why it was never chased up well you weren't anemic then no well I remember going to the gp a few years ago and he said oh your iron levels were borderline mhmm but never really took any notice of it to be fair on the last blood test in 2022 october 2022 your hemoglobin was normal but with the eye of faith if you look at your blood in retrospect if you look at your blood test although the number is technically normal if you look at the trend back in 2020 2021 look how high your blood tests your blood counts were right on the top of the green zone and then in 2022 they dropped into the bottom of the green zone so that's a quite a big drop for you although someone else might trickle around this time this the whole time yours clearly was higher and then has dropped and then at the same time the size of your cells decreased which makes us worry about low iron levels so that's kind of what we're talking about that maybe in retrospect you've been developing a bit of an iron deficiency for the last few years okay and the bleeding internally that we're talking about is very slow tiny drips of blood loss that you wouldn't notice and that over time decrease your iron levels such that you can develop anemia so not a big hosing bleed but just a very slow drip that might happen from say a polyp or a blood vessel that's very close to the surface and the reason I guess we're keen to sort it now as opposed to back then although obviously back then everything looked normal so that's 1 reason why we didn't do anything then and the other reason is that now you've been started on loads of medicines which is in your blood because of the stents in your heart yeah so that does increase you the chance of you having a slow bleed as well well except the acid some antiplatelets exactly bleed exactly that's what we're here to work out really you've been tested for celiac disease and you don't have that and you have had some biopsies taken of your small intestine where you don't have the results but they'll probably come back over the next few days to make sure you don't to make a 100% sure you don't have celiac disease and then you had that ct scan which was obviously reassuring yeah but the ct scan isn't the best not the best test to look for a problem in the lower bowel and the: and the problems I'm talking about could be benign they could just be blood vessels that are close to the surface and as poo comes past they just rub on them then they bleed a little bit it could be polyps fresh fleshy outgrowths of the bowel that the same thing happens they shear off a little bit with the poo and then they bleed a bit taking them off can improve iron deficiency taking the polyps off the other thing is cancer that's what we're really here to definitely rule out that you don't have oh something yeah like got it we have that on top of them clearly you don't have a big cancer because your ct scan is normal which is good okay but we know that if say you've got a tube your: and you've got something growing inside it like a polyp or an early cancer it's stuck together and so all we see is something stuck together on the ct scan so we need to blow it up to have a really good look on the inside of it and we can blow that up in a couple of ways we can do that with a scan where you have air blown up your bum and it dilates all of your: and then we scan you at that time what we call a ct colonoscopy or we can do that with a camera where we blow you up with air and look with the camera k the benefit of doing the ct scan as opposed to the camera test will be that you get to continue your clopidogrel and your aspirin which are obviously very important for you in this very early post stent stage and I think that would be what I would suggest would be another scan a ct colonoscopy where we look in a more detail at your: to make sure there's nothing bleeding there if we find a polyp at that time then we can talk about what we do about that and then at that. We need to involve doctor feldeman your cardiologist to work out at what. Is it safest for you to stop the clopidogrel for a week so that we can go in with our camera take the polyp off to stop your bleeding and then restart your clopidogrel after that right okay does that make sense so it's all a bit of a balancing act and we need to work it out between ourselves those are bleeding slowly but if we slice a polyp off on the clopidogrel you'll bleed quite fast and we don't want that right okay right kinda makes sense yeah and I'm obviously this is all with the assumption that you'd be happy to have that obviously you don't have to if you if you don't want to have invasive tests or more tests that's completely fine however well just rule everything out exactly however with your blood counts the way and if everything does come back fine then what well there's this big area in the middle isn't there so we've had a look down the top end or down to your small intestine the first part of your small intestine the duodenum and we're gonna have a look at the bottom end with a ct scan the: but there's all this bit in the middle you've got 6 m inside you we had to look at the first meter or so with our first camera test we'd have a look at the last 2 m or so with the lower camera test but that leaves 4 3 4 m in the middle that we haven't looked at so that is the small intestine and sometimes you can have small bleeds from there which we find it difficult to detect with our cameras because they're limited in length but we can do capsule tests where you swallow a pill camera and we look for anything bleeding at that time so it could be that we proceed to that that. Pill camera pill camera yeah it's a bit fun geez yeah wow but that's down the line and I think we can we can think about that months and months time if we haven't found anything and you've not responded to iron and blah blah blah yeah but it might and tell me about your life more generally before all of this drama what were you what what did you do do you do you work for a living or yeah yeah what do you do I run children mhmm in a nursery yeah mhmm do you drink or smoke I did smoke you've stopped yeah good for you well I'm finding really hard so I need to speak to my cardiac nurse I need to try the patches in this thing you're getting a headache slight god so hard I mean sorry yeah I've smoked for a long time I had to cut like down how long did you smoke for oh god it's got to be well my 52 now just turned good probably 30 30 years yeah happy day for that time yeah mhmm I have stopped a couple of times in between that but but good for you stopping yeah have a lifetime yeah I know but I think I need the old vape thing yeah that she was on about I can copy the cardiac nurse in so they can liaise with you about that because it's very important that you stay up isn't it you know yeah on your heart I know but it is hard I mean I was giving up anyway so this kind of just like mhmm but yeah yeah but what what a push yeah exactly jesus and you might stop slowly I was alright hospital I was like yeah yeah you know but out of sight out of mind so sleep you can't smoke it's like detox you and then you go home so you don't use and then everyone's smoking yeah and then I got home and I was like the first few like few days is fine but after that I was like do you live with anyone at home no I live with you that's something good isn't it because if you had the partner or someone else around that smoked would be possible does she came around christmas day was like that yeah out not that I smoked in my house anyway never still very far out I know I said to and she was gonna sit there and roll 1 on the table and I went get out yeah and she was like I'm not smoking I said jeff I can see it yeah that's not fair and how's your weight been are you losing weight at all no I I did lose about nearly 5 stone and over the last 11 years because obviously I asked the nurse how much I weighed and I was like okay so over the last 5 years you've lost 11 stone you think well no I I lost 5 and a half stone 11 years ago okay so and the last 11 years well I suppose the last I would say 2 2 years I've put on probably a stone and a half okay which I knew I had because my you know you can tell in your clothes but I just don't weigh myself because understood depressing isn't it no no but it's only christmas so it's fine yeah yeah so so yeah so and it's just I don't know what it is it's just exercise you know I got into that rut of you know I lost a lot energy years ago and oh I'm sorry yeah it's not not been an easy ride you get into that can't be bothered yeah can't be bothered it's hard to self motivate isn't it really hard so yeah so because I used to be quite active so mhmm just got walking a lot swimming mhmm right so can't do that for I think still about 3 months okay I think is it I don't know to be honest with you I don't know no they told you to do it they start you on any iron tablets no no would you like some I've got a had 1 iron infusion you have that infusion and I've got another 1 on tuesday great so that'll bring it's already bringing it up because he was 90 and now it's a 110 so by the time you have that next 1 it'll go back to normal I think you get to be replaced with iron that last or july it's about 3 months worth of iron in each 1 so it should top up your stores for a couple of months for us to get all these investigations sorted and work out what's going on oh okay and then we can decide what to do if we can fix it easily without cameron then we can if it's more difficult to fix then we can put you on some long term iron and do something else it all depends about what we find k so so essentially I would suggest having a colonoscopy at this time stopping your blood thinning medicines is a bit risky and I think I need to talk to doctor feldman about what we do there and think a good compromise would be a ct cat ct colonoscopy so that's what I think we're gonna do but I'll just check with doctor feldman to make sure that he's not like oh well just stop them because if what I suspect will happen is you'll have a ct colonoscopy we'll find a polyp and then you have to have another test do you know what I mean whereas if we could get it all done in 1 you have an actual colonoscopy we have a look around we take off the polyp at the same time brilliant yeah that's all all done in 1 go instead of having 2 separate tests with radiation and bowel prep and all that stuff that's why I'd suggest and I'll chat to doctor feldman to work out what whether he's happy to stop your so what's your ct that we just the ct colonoscopy it's just like the ct scan you had yeah except 2 differences the first difference is you have some you have a drink for the days before the test usually for the 5 days before the test you drink something twice throughout the day which tags all of the poo so we know what's poo and what's not sometimes it gives people a bit of loose stool for those days it kind of clears you out a little bit but not like full bowel prep so then it tells you what's poo and what's not and the second difference is that you go into the room on your side we pop a small catheter up your bum a tiny tube and then blow air up the catheter and then we ask you to roll so we scan you in several positions so the poo moves around the air moves around and we get good pictures of the whole of your: to work out what's going on okay lovely but it's a bit more a bit less invasive than having a having a full colonoscopy because you don't have the full prep which is quite an undertaking okay but if you just have to have it done once then I think that having a colonoscopy is fine for you you could manage it have it same very similar to the ct colonoscopy except you have to have a low residue we recommend having a low residue diet which is bland food without seeds and lots of fiber for the few days before the test as well right we can talk about all of that once we work out what to do so either ct scan or colonoscopy depending on what doctor well what 1 would the ct scan the air bottoms up better than the camera sounds better camera up yeah good I think it is better and it will tell us what we want to know and then in the meantime you're having iron infusions to chop up your iron counts which is great yeah and you've had the test for celiac disease and you don't have that so fine so you've got a bit of a plan so we'll do a ctc or a: and I'll discuss with doctor feldman how long he wants you to have your ticagrelor I know 1 of the sotropyl consultant came to see me on the ward mhmm 1 of your team said that the camera at the bottom but that won't be for a while because exactly I've just had this exactly and it put too much strain or something it doesn't necessarily strain or or whatever it doesn't necessarily strain the heart too much colonoscopy itself it's just that the problem is stopping the blood thinners exactly we don't want the the stents in your heart to clot up again I we have to stop the blood thinners like a week around a colonoscopy because so yeah what I suggest is we what I suggest is we yeah the other 1 we'll do a ct scan and make sure there's nothing worrying going on the other 1 good sounds like a plan right alright okey dokey I'll just have to start my lecture with everything and then probably do a ct okay I feel like I any in this hospital sorry that's fine at they pay me to come in at least they pay me to come in yeah I know I've the pain to come in alright thanks so much nice to meet you paul see you later thank you as a plan probably pursue ct colonoscopy but discuss with doctor powers + or - doctor feldman as to whether full colonoscopy would be reasonable in the context of a dual antiplatelets recommended for the next year and an mi in mid december on examination height 159 cm weight 77 kg and b mi 30.5 dear gp I had the pleasure of meeting missus stanton in iron deficiency anemia clinic on behalf of doctor powers the consultation was face to face sounds as though she's had a challenging year or challenging few months I should say with coming into hospital and suffering a st elevation myocardial infarction and undergoing primary pci she was found to be anemic around the time of that and underwent an ogd which didn't demonstrate any clear cause for her anemia but and so she's been referred to clinic today to discuss our next steps during her inpatient stay she also had a ct abdomen and pelvis which didn't demonstrate any concerning lower gi lesion however there was no preparation and there was no air insufflation on this ct I note that her ttg has also been tested at normal <\n\n> Looking back at her blood test I can see that her blood counts dropped and her mcv dropped sometime between 2022 and now and her most recent blood test showed that she was quite quite anemic well she was in hospital with a hemoglobin of 90 and microcytosis and a low ferritin so the picture is certainly consistent with iron deficiency <\n\n> She doesn't have any lower or upper gi symptoms her weight is stable she says that over the last 2 years she's gained about a stone and a half <\n\n> She's been having iron infusions and these have increased her hemoglobin up to a 110 when last checked and she's due another infusion next week <\n\n> In terms of her life more generally, she looks after children in a nursery she has a 30 pack year smoking history and has stopped smoking now which I've congratulated her on today she does say that she's struggling a little bit particularly around the christmas. And seeing her relatives who smoke and she would be grateful for some further input from the cardiology team to help her stay off the cigarettes wonders whether she may need an inhaler later I'll copy the team in to this letter so they can get in contact with her she lives by herself full stop paragraph we discussed today that her anemia makes us concerned about slow blood loss in the gastrointestinal tract there wasn't anything concerning that we saw on our upper gi endoscopy however the ct scan that she had doesn't confidently exclude any problems in the: that could be causing bleeding these problems could be benign such as blood vessels close to the surface precancerous like polyps or indeed could be small early bowel cancers and she's aware of this we'll start <\n\n> She would be fit for a colonoscopy however her taking dual antiplatelet therapy and planned for ticagrelor for the next year in the context of her recent cardiac stenting makes me reluctant to arrange this test as we'll have to we we would recommend stopping her ticagrelor for the 7 days around the test this therefore means that we could consider undertaking a ct colonoscopy which wouldn't necessitate any cessation of antiplatelet therapy subsequently if there's a polyp detected we could then discuss with the cardiology team as to the best the optimal time to pursue colonoscopy in the context of her cardiac disease and antiplatelet therapy I look forward to my discussions with doctor powers and doctor feldman as to work out the next best step yours sincerely