So there's a referral for christine pengelli 745758 89 year old lady who's currently on stannenwort in g 5 background of atrial fibrillation hypertension heart failure osteoarthritis bilateral hip replacements osteopenia mixed anxiety and depression and a colles fracture in 02/2009 I have issues list number 1 decompensated heart failure then bullet. Most recent echocardiogram march 2023 lv normal in size with borderline lvh and ejection fraction in the region of 55% mild mitral stenosis and mitral regurgitation holter monitor march 2023 atrial fibrillation with a short. Of slow ventricular response 38 nocturnal pauses 70 to 42 beats per minute and then next bullet points on intravenous diuresis having received 40 hundred and 40 mg of furosemide intravenously today and then next bullet. Chest x-ray june 14 demonstrating fluid in the fissure but no large pleural effusion on the right cardiomegaly poor quality film possible underlying pleural effusion on the left and then next bullet. Ultrasound abdomen june 17 small right basal pleural effusion noted incidentally issue number 2 or actually still in issue number 1 next bullet. Oxygen requirement increasing today requiring 28% venturi issue number 2 treated for community acquired pneumonia with gammoxiclav day 2 inflammatory markers crp 58 on admission increasing to 182 white cells 12.4 on admission improving to 8.1 with antibiotic therapy issue number 3 possible urinary tract infection pus noted on catheterization ultrasound demonstrating unremarkable normal unremarkable abdominal and pelvis and then next issue constipation valve's not open for 5 days on senna 15 mg at night laxita 1 seshoe twice per day but has been using opiates with codeine and morphine used over the last 2 days next issue electrolyte abnormalities mildly low magnesium noted on today's bloods replaced intravenously the remainder of electrolytes are normal the next issue iron deficiency anemia with hemoglobin 96 on admission and transferrin saturation 8.8 so observations venturi 28% with saturation 92% respiratory rate 24 blood pressure a 149 over 59 heart rate 65 temperature 35.4 stably low throughout admission his talk chart review bowel's not open since admission blood sugar 5.9 on last check carcinoma multiple times today oh my god lag would bust in a minute then after catheter fitted 2,750 milliliters passed since midday no background lives in a residential home not for cpr in bed nasal cannulae oxygen with saturation is 98% on monitor aware of where she is at the moment however not aware of time but aware of person so orientated to person and place but not time mumbling repetitively about breathing but appears to be reasonably orientated particularly in the context of acute admission on examination right lung absent breath sounds to the mid zone but clear above this left side absent breath sound in the bases but clear above this heart sounds normal good pulses but irregularly irregular in atrial fibrillation no peripheral edema tongue dry impression most likely urinary tract infection as a cause for initial presentation with urinary retention secondary to this leading to fluid overload and challenging diuresis leading to hypoxia with large pleural effusions plan continue input output monitoring stool charting and regular observations no further furosemide denies has had significant diuresis already and at risk of acute kidney injury usernese check tomorrow morning hold tomorrow's morning furosemide dose pending u and e results continue to wean oxygen as able target antibiotics for urinary tract infection send midstream urine sample for analysis chest x-ray to exclude hospital acquired pneumonia and pneumothorax as a cause for respiratory deterioration although improvement with diuresis makes these less likely update family as has been told about poor prognosis by the stannen team