Transcription - 20250412T 15-04.mp3

Alan haines f 8 8 2 2 8 4 80 year old man creatinine 97 at baseline electrolytes normal crp 3 neutrophils 13.8 with white cell count 15.2 hemoglobin 132 iron 1.9 lft is normal blood gas normal june 2024 subsequent strokes post stroke seizures are admitted for these april 2025 in terms of the stroke he was found with left side weakness on the floor at the june 2024 nahss on admission 6 and nhss on the post op ward round 10 imaging demonstrated multiple lacunar infarcts he was also treated for an aspiration pneumonia admitted for his post stroke seizures october 2024 and april 2025 previous history of alcohol dependence not seen gp in 40 years prior to presentation in june 2024 most recently admitted with further post stroke seizures january 2025 eeg at this time demonstrated sharp waves of the right frontotemporal region and excess irregular slow activity in a similar distribution medication history atorvastatin 80 mg in the morning <\n> Baclofen 10 mg twice a day <\n> Clopidogrel 75 mg in the morning <\n> Doxazate 100 mg twice a day <\n> Lanzoprazole 15 mg in the morning <\n> Lemturazepam 1 g twice a day <\n> Thiamine 100 mg twice a day <\n> 0 base 11% cream apply to the skin as required no he's on make sure I'm on yeah I'll find 1 thank you history lives in a care home history of presenter complaint found unwell by care staff this morning full stop less responsive, noisy breathing full stop known aspiration risk full stop <\n> Only responsive to pain with ambulance crew, hypoxic, tachypneic full stop evidence of vomit on clothing no history from patient as unresponsive investigations he's also had a chest x-ray full quality film slumped to the left no clear focal consolidation other investigations ecg sinus rhythm first degree av blockade rate 97 sinus rhythm and then observations heart rate 100 saturation is 100% respiratory rate 21 blood pressure a 45 over 71 hi mister hanes no response to verbal stimulus hi mister hanes hello open your eyes for me open your eyes hello how are you so so gcs wise 335 which gives me 11 how are you mister haines how are you feeling has anyone told you where you are at the moment how are you feeling talk to me you got any pain anywhere k have a little look at you good regular pulses feel a bit warm to touch it's been a soft systolic murmur which doesn't radiate no peripheral stigmata of infected endocarditis in the hands or the toes left sided weakness post stroke side okay tommy's soft and nontender quick listen to your chest alright take us a big breath for me decreased breath sounds in the left base fine and you're a bit hot to touch aren't you under where your infection is still warm on his legs there's no cellulitis no peripheral edema oh no he's some peripheral edema to the knees bilaterally okay that's fine great need to cough all this stuff up you're gonna cough that up you wanna sit forward a bit so you can cough that up need to bring it up and the plan is get some blood cultures if you spike a fever give you some intravenous antibiotics while you're in hospital with us as well as some intravenous fluid I'll get you some paracetamol for your temperature we'll get a culture of this stuff you're coughing up a sputum cns we'll check your urine to make sure you haven't got an infection in there and see where there's an infection there we'll send a catheter sample of your urine because you've got a catheter in situ and we'll take it from there is that okay any questions no make sure you cough all the stuff up alright I can get you a saline nebulizer to cough it up okay

```json
{
  "mrn": "F882284",
  "content": "Medical ST4 Miller Clerking\n\nPresenting Complaint:\nDecreased responsiveness, noisy breathing\n\nHistory of Presenting Complaint:\nFound unwell by care staff this morning. Less responsive with noisy breathing. Known aspiration risk. Only responsive to pain with ambulance crew, hypoxic, tachypnoeic. Evidence of vomit on clothing. No history from patient as unresponsive.\n\nPast Medical History:\n• Multiple lacunar infarcts (June 2024)\n• Post-stroke seizures (October 2024, April 2025, January 2025)\n• Left-sided weakness post-stroke\n• Aspiration pneumonia (June 2024)\n• Alcohol dependence\n• Not seen GP in 40 years prior to June 2024 presentation\n\nMedication History:\n• Atorvastatin 80mg PO mane\n• Baclofen 10mg PO BD\n• Clopidogrel 75mg PO mane\n• Docusate 100mg PO BD\n• Lansoprazole 15mg PO mane\n• Levetiracetam 1g PO BD\n• Thiamine 100mg PO BD\n• Oilatum 11% cream apply to skin PRN\n\nAllergic History:\nNot mentioned\n\nSocial History:\nLives in a care home\n\nOn Examination:\nGCS 11 (E3 V3 M5). No response to verbal stimulus. Warm to touch. Regular pulses. Soft systolic murmur, non-radiating. No peripheral stigmata of infective endocarditis in hands or toes. Left-sided weakness post-stroke. Abdomen soft and non-tender. Decreased breath sounds left base. Bilateral peripheral oedema to knees. Productive cough.\n\nInvestigations:\nBloods: Creatinine 97 (baseline), electrolytes normal, CRP 3, neutrophils 13.8, WCC 15.2, Hb 132, iron 1.9, LFTs normal, ABG normal\nChest X-ray: Poor quality film, slumped to left, no clear focal consolidation\nECG: Sinus rhythm, first degree AV block, rate 97\nEEG (January 2025): Sharp waves right frontotemporal region, excess irregular slow activity in similar distribution\nObservations: HR 100, SpO2 100%, RR 21, BP 145/71\n\nImpression:\nAspiration pneumonia\n\nPlan:\n1. Blood cultures if spikes fever [_]\n2. IV antibiotics [_]\n3. IV fluids [_]\n4. Paracetamol for temperature [_]\n5. Sputum culture [_]\n6. Catheter specimen of urine for culture [_]\n7. Saline nebuliser to aid expectoration [_]\n\n----- \nSummary:\n80-year-old man with post-stroke seizures and left-sided weakness, lives in care home, presents with decreased responsiveness and noisy breathing, likely aspiration pneumonia.\n\nAI Diagnosis:\nAspiration pneumonia in the context of known aspiration risk, post-stroke dysphagia and evidence of vomiting. Differential includes hospital-acquired pneumonia given recent admissions.\n\nAI Plan:\n1. Empirical broad-spectrum antibiotics (e.g., co-amoxiclav) to cover aspiration pathogens\n2. Oxygen therapy if required to maintain saturations\n3. IV fluid resuscitation\n4. Blood cultures before antibiotics\n5. Sputum culture and sensitivity\n6. Urine culture to exclude concurrent UTI\n7. Speech and language therapy assessment when stable\n8. Consider nasogastric feeding if unsafe swallow\n9. Regular chest physiotherapy\n10. Monitor for seizure activity given history",
  "summary": "80-year-old man with post-stroke seizures and left-sided weakness, lives in care home, presents with decreased responsiveness and noisy breathing, likely aspiration pneumonia.",
  "investigations": "Creatinine 97 (baseline), electrolytes normal, CRP 3, neutrophils 13.8, WCC 15.2, Hb 132, iron 1.9, LFTs normal, ABG normal. Chest X-ray: Poor quality film, slumped to left, no clear focal consolidation. ECG: Sinus rhythm, first degree AV block, rate 97. EEG January 2025: Sharp waves right frontotemporal region, excess irregular slow activity in similar distribution.",
  "tasks": [
    {
      "item": "Request blood cultures",
      "time_frame": "2025-05-25T14:06:00Z",
      "request": "Please take blood cultures if patient spikes fever. 80-year-old man with post-stroke seizures, found unresponsive with noisy breathing, suspected aspiration pneumonia. Currently on antibiotics."
    },
    {
      "item": "Request sputum culture",
      "time_frame": "2025-05-25T14:06:00Z",
      "request": "Please send sputum sample for culture and sensitivity. 80-year-old man with productive cough, decreased breath sounds left base, suspected aspiration pneumonia. Known aspiration risk post-stroke."
    },
    {
      "item": "Request urine culture",
      "time_frame": "2025-05-25T14:06:00Z",
      "request": "Please send catheter specimen of urine for culture. 80-year-old man with indwelling catheter, presenting with decreased responsiveness, to exclude concurrent UTI as source of infection."
    },
    {
      "item": "Follow up culture results",
      "time_frame": "2025-05-27T02:06:00Z",
      "request": "Review blood, sputum and urine culture results. Adjust antibiotic therapy according to sensitivities if required."
    }
  ],
  "feedback": "- Missed opportunity to document full neurological examination given history of stroke and seizures\n- No mention of seizure prophylaxis review despite recent seizures and current admission\n- Failed to ask about or document recent oral intake/feeding history given aspiration risk\n- No safety-netting advice documented for care home staff regarding seizure monitoring\n- Missed opportunity to clarify antibiotic choice - 'IV antibiotics' is too vague\n- No mention of DVT prophylaxis assessment despite reduced mobility\n- Failed to document capacity assessment or best interests discussion despite patient being unresponsive\n- No clear escalation plan or ceiling of care discussion documented"
}
```

Summary

Investigations

Plans