1 on towel would you be able to sleep a chili and food for you or or just try gluten free 67274 cheers thank you bye 62 year old lady past medical history type 2 diabetes hypertension previous breast cancer medications list anastrozole 1 g once a day pregabalin 25 mg bd metformin 1 g bd modified release atorvastatin ramipril 2.5 mg once a day calcitube d 3 allergic acid 70 mg every saturday add osteoporosis to the to the problems list and mounjaro has been on for 18 months living in holsworthy north devon access team medication list on gp record thank you cheers bye observations temperature's 86.6 heart rate 87 respiratory 18 blood pressure around 11 over 72 so that's 95% on air investigations using his normal lfts bilirubin 22 previously has been 9 elevens and no previous background of low grade jaundice similar to gilbert's alt 22 which is at patient's baseline and alp 39 which is also at patient's baseline amylase normal crp 4 urea 11.1 from 5.6 I barely take I've had ast normal full blood count white cells 12.9 from 7.2 neutrophils 11.61 from 3.71 I went home and planted some gin and tonic but I didn't feel so so great this morning oh morales do have pain well I'm trying to help you I think people not not you no hello sir hello there I'm rob I'm 1 of the doctors how are you you okay yes thank you good I'm glad I came to have a chat with jill but obviously we put 2 patients in this room oh well a day room that's what I yeah they'll have a day room exactly that's what I find oh have you got a bed space sir or and you've just come to just have a sit is that right I'm just reaching out to me oh I see I'm sorry hang on a 3 fine is okay is that okay yeah thank you so much I'm very old to be so I kind of did about it from auriglio the consultant who you saw in the pt who was saying that you're having you've been having pain for a while now on and off in your epigastrium anywhere else other than your epigastrium it's just literally there the whole time yeah doesn't go anywhere else it's just there eating drinking any change to the pain no nothing trees it or makes it worse no I've tried to think about that there's it's been noticed it in january hospital medicine gp etcetera she put me on well I had a metso and lantus so not had the oh 0 you had the lantus mhmm she wants to put me on those again I was well it didn't work for me mhmm so I asked for the famotidine yeah fine and that didn't work either not at all even after the day 1 it didn't work mhmm after a month nothing it's just exactly the same so when I spoke to her she said well I can put you on esomeprazole mhmm and she said we'll see what it's like in 2 weeks so I can refer you to gastropares I said just refer me to the gastro so she did a choosing booked referral because obviously I'm more bad still awake yeah of course you live yeah okay I do yeah so that she sent that off on the march 4 mhmm I actually have not heard anything heard anything at all okay and then it just kicked off big time mhmm so what happened yesterday and what way did it change well I was at work I was quite happy in the morning mhmm and then late morning the pain just took over mhmm and I went mhmm very severe yeah had gastric pain yeah radiating anywhere no no not moving a creek no here we are I'm here no alright change to your bowels at all no nothing like that completely nausea vomiting or nausea no I'm a bit of nausea but I'm 1 of these people that I'm nauseated every morning mhmm but that's just been a long term thing more clinically yeah I have to sort of manage it mhmm and what's the time scale that's been going on for how long now this epigastric this one's been on since january since january what changed in january I've no idea I've looked at your regular medicines and all that kind of stuff I can see as you said you've been on lots of antacid medicines in the past some ppis and stuff but you they gave me pep tack downstairs yesterday it was a good it really burned I felt a real burn after I'd had it mhmm which I thought yeah no it's definitely not meant to do that yeah but it really did burn mhmm but my gp thought I was feeling a little bit ott because of my diabetes okay when have you when did you start the mounjaro must have been about 18 months ago so I've not had any issues right for for a while no and I'm on the 7.5 okay it's quite a good dose it well it's not low dose I don't particularly want to go any higher if I'm honest yeah and then of course obviously I've read things like pancreatitis and mhmm and stuff which is normal but 73 in february and it's 40 yeah 40 something thousand yeah neutrophils are a little bit up on your blood tests have you been vomiting or no no your bilirubin is 23 normal range is 21 it's always been single figures or low double figures before so it's a bit unusual for it to be up but the rest of you look at tests are normal sometimes when you're ill for other reasons can develop errors like usual behr's syndrome some people get that but I can't see on your gp bloods if you've been in and out so classically people usually beers do and the pain does it come and go or is it just there the whole time constant dully constant dully constant dully and then all of a sudden it'll just flare up particularly severe and nothing triggers it as you said no position mhmm bending over no mhmm no I've tried all sorts of positions and have you lost a lot of weight on the monjaro I've gone from 90 yeah 18 I suppose I see over 18 months yeah yeah so not rapid rapid weight loss because sometimes that can yeah no it's it's not been a rapid and then I put a bit on over christmas seem to be hovering around the 82 mhmm but then my hba1c was 60 on your nhs on my care thing fine I guess maybe you had it with your gp in york but that's why I was saying it will be yeah awesome that sounds cool yeah but yeah and moving around makes the bed the pain worse does it make it sound good yeah I mean I'm quite happy lying still but when I get up and moored around and at the moment I'm going a bit like ugh bit of lightheaded and stuff mhmm okay can I have a quick look at your eyes I think I'm gonna look at your head I'll hold my ultrasound shingell because I was trying to explore whether we could get an ultrasound today but unfortunately I went out to the clinic so I was just giving it a try myself I think that's alright that's fine no other symptoms associated with when the pain gets bad you don't get diarrhea or anything like that no you're just too young that's alright you'd back to bed a little bit of course is it forward I have a listen to your back thank you can't hold legging or anything like that no no good and then hold to the kevin yeah with anyone else nope no my kids are down here I moved back when mom died so I was intended to go back home mhmm do you like living at home no or do like the work no I just go home open the door and it's just like it feels like a rip in the world mhmm so quiet back garden just looks out of kids yeah mine is so relaxing and you look at don't you someone to relax after at work and I've got I'm just gonna put my glasses on I've got a farm over there so some days all you hear is the farm machine and for days you just hear the birds mhmm they're back up oh that was loud so she's yeah I was worried that I should have been working this weekend oh really yeah that extra mile you're contracted yeah right but it's just not a good place no it's not saying that normally I'm just I'm having serious breast cancer I have illnesses for a real length of time like when I had cancer and stuff but it's not I read about that breast cancer in the past it and did you have surgery for that mhmm I had a lump pet here and I reduction at the same time mhmm so that didn't quite get a plan ar vein right and you've been on the anastrozole since I've another 1 and a half years okay and you've got diabetes and you've had that as well since I was 45 I for 22 years now okay and high blood pressure was it as well yes yeah although that I wouldn't need to go out oh good fine that I'm in where I'm proud of myself mhmm yeah good could I have an appointment with the pharmacy gonna take look and see if there's anything in your liver stones or anything like that that might be causing it because you never had any abdominal imaging as part of the trial it's the gallbladder out I haven't fine when was that february mhmm like in the sixties I don't and you had been in clinic then yeah and does that feel like they lose you no I still have to lose my head know fine but comt alright think if you like it I'm gonna have it you like watch that a bit of mist to put in the day ring I'm sorry I don't know you have to put any patient in for me that's a little bit more it's a bit yeah I guess it's better than being overweight to me but only marginally surely is it sore or unpressing it's tender tender do too much sorry I've asked it to do too much all at once there you go good so same thing the middle which is the stoplight we're looking for the vessels but you can drain the liver so we're looking so you're seeing your inferior vena cava below your liver looking lovely your liver is a bit fatty but with diabetes it's hard to avoid that and now we're looking just at your liver hilum which is where the liver comes from rose embryologically and we're on the vessels that coalesce when did you last have sleep in food breakfast oh that long ago so does he love anything else so this is your duodenum that we can't see through leaping around and this is your bile duct here I can't clearly see anything in it just with the jaundice I wonder whether you may have retained stone or tiny bits of grit coming through the duct which can cause you to get an emesis like jaundice but usually it would cause your liver enzymes to come up as well as the ducts become irritated but that hasn't happened for you as I've been told many times I am not a straightforward case really I'm often told that when I'm pressing firmly here it's it's tender but not particularly painful no but it is very tender very tender any have you got a good view of the building or not really know nice work and coming around so you've been to hospital and non school with this frankly for them yeah you know it was the first time coming with it yes I'm afraid I'm a typical medic I hold off as long as I can yeah I'm I'm the center we're doing these side effects again this is nice view of your liver and your kidneys together I'm not clearly seeing these things in your gut you need a formal ultrasound for someone who does just these obviously if I'm lightening just moonlighting doing them so here's your technique you can see me on the duct it looks quite lovely there we go a big breath in for me lovely and just and you need to breathe in here just breathe and I'll ask you do the same thing again that's okay raise the liver down just get some ice for you there so what would you like to do about it there's a couple of things it could be it could be nothing it could be discomfort from the buildup of the glp-one the mungari if they're on that can cause upper gi discomfort it just needs to stay your stomach for a really long time can cause reflux or if you feel uncomfortable often you get unpleasant gi symptoms afterwards 1 thing there could be a tiny bit of grit coming through your ducts there could be a bit of grit coming through your duct which can cause a tiny bit of jaundice I would usually expect your liver function tests your liver enzymes to go off and yours happen so it goes against that but it's always possible when you've got pain and slight bit of jaundice whether you've got an infection or a bit of grit coming through your duct and the I guess the other potential is poor anything else going on you know abdominal pain is poorly localised isn't it so it's difficult to where you say it is is it always where the actual so problem is we've got lots of things we could do about it I could try and speak to them in the audience and try and do try and get you a ct scan there would be cross sectional imaging can get lots of information but it's obviously radiation which is obviously nice to avoid when you can we can try and get an ultrasound scan we're not going to get 1 today so you'll be stuck in hospital until monday waiting for an ultrasound scan which we can do and that's absolutely fine that would avoid some radiation and it would give us a good amount of information probably all the information that we need to avoid some eye support or we say that this is something that's been going on for a while we give you painkillers we try and get you feeling better and see if we can get you out and pursue outpatient investigations with probably an upper gi endoscopy would be essential starting about the age of had such a traumatic experience and what have you did you sorry yeah did you have station well I came in and I had a double ender mhmm but apparently there wasn't a gastroscope available so they did the colonoscopy first first and then did the I mean you never do a colonoscopy first anyway do you that's what happened the cats and then you I can't I can't really picture was it here yeah I can't really picture it in person in my head against the bone allowing and I can't stand it awful and I was just forced that was awful and you were sedated well I'd had sedation for the: obviously at the wall and all the time I got it how horrible and you were an endoscopy nurse then no no no I was a urology 1 then still a colleague I was like yeah no I wasn't experienced at all so it would be sufficient I can tell you yeah and I guess the fourth option is I can ask doctor summers whether he'd be able to come down and see you and we could talk about it and try and get a bit more information from him his view of the situation is okay but obviously you come into hospital with pain that you couldn't manage at home so I'm keen to find out an answer for you I mean I've I've had paracetamol or more whilst I've been here wouldn't make it better make a vast difference mhmm mhmm yeah I mean I just go by whatever you think is the best option I don't care what it is but I mhmm all I want is for something yeah of course what it is yeah fine I think the best chance of finding out what it is today is gonna be going for a ct scan but it obviously comes with with radiation and incidental findings and all that kind of stuff and the best low radiation chance of finding out what's going on is having an ultrasound scan but like I say you'll have to wait today and tomorrow in the hospital and the day after to get that done if you wanted to have that as an inpatient so I guess it depends on whether you'd manage where want where you want to be basically where you want to be here or whether you want to be at home and then I can work out what what to do based on that I don't mind oh I know it sounds awful but now I'm here I thought we're just staying yeah that's fine we'll get it sorted get it sorted yeah that's fine I understand yeah sounds good fine let me speak to my boss then let me speak to doctor sellers okay as long as you're happy for me to do that of course and let him know that you're here because yeah I think I already told you spoke to already told him that you were here and I think it's yeah obviously you're 1 of our nurses so they'll nice be able to come and see you and make sure that you get all the best care that you're having here and then what we plan about what to do does that sound alright yeah that's very helpful I'd like to see if only you wish it was under better service is that a penicillin yeah it's what can I get you this back as a pain reliever I'm sure what 1 you have it's like a pill do you think you can take a price of the meal no I don't know I'll give you the pap yeah 5 mils okay I think mhmm it's 10 mg anything like that about okay and you're on a 50 dose so you can have more if that's because I you know opiates are obviously very good for people okay well no no no no I didn't take any of it no ibuprofen funnily enough there is a lot of sore downstairs but I've got to do some of it now I meant to take them in a jar today mhmm are we gonna leave that off yet let's take it off and see what happens so that 7 days ago that I would have taken it off mhmm yeah fine I think that'll be good never know it might wash out and you might feel a bit better the symptoms it can cause are kinds of unplanned yeah side effects discomfort upper abdominal discomfort is a classic 1 of those you know we see lots of people in upper lists as I'm sure you know that come in yeah with weight loss and upper and dyspepsia and it's all because of ben lunjaro yeah yeah but it's good to exclude anything else going on obviously I've got I'll leave that now so I've got this gentleman who's here with me but I'm not in the mirror he's got something connected the tubing is in the back like it's just completely like I went to the back and it's like dark urine I can see something above in it but then when you go for up on the cheek he was starting to feel and it's just completely black so you're not done by all she's yeah he felt he said he he was fine for he called for 2 to 3 hours to get his bed so maybe it's a bad thing yeah because otherwise he's got like no fevers his blood's all pretty okay he's been functioning his baseline now ck hasn't been done should be like that but yeah as long as she's flushing it nothing's gonna work mhmm she's flushed it though so that's not any concern sometimes I can have a when you've got a bladder and if you lie in bed and you've got an entry? At the top and you flush the thing and it might just sit in the back right there