Patient is sylvia lingu foxtrot 865376 investigation is creatinine 894 with urea 24.3 and potassium 7.1 open brackets hemodialysis patient close brackets alp 1 6 9 alt 68 d dimer 1.3 hemoglobin 1 1 3 stable respiratory rate 18 breaths per minute oxygen saturation is 97% on air blood pressure 155 over 98 pulse 87 temperature 36.6 degrees celsius with a background history of he also reports pain up on examination were there which were on ticket yeah capillary full time was normal it's crackles no okay causes no other signs of clubbing you always like to look into maybe something like heart failure or ckd I think I'd like to use the wells score and then see ecg. You've seen your ecg yeah yep I've seen that got an ecg mhmm rate 96 so that was taken rhythm is fine qt refill range is fine but that's the only 1 where they'll if you're on yeah otherwise so the p p wave is present qrs complex is present it is on the long side I agree it looks prolonged it looks prolonged to me yeah but it is technically within limit within limit yeah no signs of any like st elevation or anything like that or hyperkalemia in the patients so oh yeah ecg is normal normally mhmm for bloods we like to like fbcs check for any signs of infection or anemia yep using these again check her electrolyte counts yep for any of medications that she's on because of her ckd and stuff do like liver tests and renal tests as well mhmm I've got her blood injections on the computer we can go and look at them so you wanna have a look at her full blood count it shows she's slightly anemic neutrophils are slightly raised from memory we can go and have a look at them what are the tests you wanna do crp if any signs of infection yeah with nutrients in your hands on that and also because like you wanna rely on your feet to be done yeah think they're all very reasonable to think do I wanna do a pe do I wanna do a b dimer at 1 1 0 rate is the tpn okay I can tell you that it has been done and it's high 1.3 as a rule out test anything's eg4 so I'm not sure her egfar is 4 4 4 4 4 4 okay she said she said 7% so we wanted to do it but she has she's an hemodialysis patient yeah so we can't really trust this creatinine if she would do have dialysis tomorrow then the creatinine of 900 which is what the egfr is calculated on so the egfr is an estimation of your glomerular filtration rate based on your creatinine so it's entirely derived from the creatinine and the age of the patient and an estimated weight so that's what gives you that number often renal patients renal consultants would describe it to patients as you say in my% they'll use the egfr as% so they're working at 7% or 4% or whatever but now that they're on hemodialysis it's unhelpful because if they're in renal failure their creatinine is gonna go up and up and up for the week before they're dialyzed and then they get dialyzed and then it'll be about 50 and then the day after if I took both of your kidneys out now and threw them in the bin your creatinine would be normal today normal tomorrow and then maybe the next day it would start to go up and it's just like that for renal patients they're completely useless often so you dialyze all the creatinine out and all the other waste products out and then the creatinine will build up until the next dialysis session so she's probably she's gonna be due dialysis shortly because I'm just asking 71 so yeah yeah I would've did did you ask her when her next dialysis session was booked well she said that tuesday's wednesday's and thursday she works as a housekeeper and then she has dialysis on the saturday so she would have just had it she should have just had it oh fuck so then for the pain then considering yep she was asking like a pe I that's very sensible I think yeah I think your differential's good if you know it's p then that's pretty sensible and we'll do a d we'll do a ctpa for her would you do a guarantee of the mammograms on her could I'd like to listen to her chest and see what it sounds like but the ctpa will also give us some information about what's going on in her chest okay but overall yeah great uk stimulus sorry alright yeah so the the I think that's been that's the bit you've actually discussed yes did I my time we're going to yeah yeah have you ordered it I haven't but I need to work out when the next dialysis session is when was her last 1 I don't know yet these guys say they have it on saturday she looks like she has post dialysis bloods on the 20 fifth so it looked like she probably got dialysis on wednesday but I have to ask her oh we don't have bloods for today yet we do these are today's bloods alright I have not had them it looks like she's due gonna be due dialysis relatively soon potassium 7.1 sounds like she might be at bed right yeah scan and dialysis I would think so we would rather just book it down book a bed yeah you're probably right you want that yeah I'm sure you're right I'm they can liaise everything they want I'm sure you're right it's too ambitious isn't it I was thinking could we get her a ctpa and then she'd go to a normal dialysis session tomorrow well I mean if if we are sure that she had it yesterday she's not going to get it tomorrow no because of course it'll be 246 yeah yeah exactly yeah yeah yeah you're right cool we'll book her right back I'll book her right back thanks are you gonna have an exam for an hour just to go yeah sure I'd love to okay great hello so you said it's a nice face hi he's here I'm paul from another medical nurse nice to meet you thank you for talking to our lovely medical students they've told me no it's fine don't worry they've told me everything that's about what's going on I'm sorry to hear that you've been you've been bringing up blood and your cough for a couple of days and you've been feeling more short of breath for that time as well feeling more breathing out of breath yes I don't feel I don't breathe hard okay and how are your legs can I see a swollen leg swollen why doesn't be swollen does it yeah so I'm just gonna you just doing that so the edema goes up to the knee or mid shin perhaps she's just had her legs down this way so as an alternative to congested here no yeah here right here sore not strong enough yes okay fine a little bit tender yeah nothing major so yeah it's relatively similar at the tube to your tube yes I'm a little bit but sometimes 3 years ago I have been here for 3 months mhmm and you have hemodialysis yes I have dialysis I I have dialysis mhmm but when did you when did you last have dialysis friday friday fine so it's only 2 days ago yeah okay fine and did the dialysis session go okay and then you were on for the amount of time that you're meant to be on and start some problems sometimes I take more fluid I have pain kidney I have cramp during dialysis or now no no you have fistula fine it's working well yeah feels like it is good I have next week next week same fine okay to make sure it's working that's fine gonna have a listen to that is that alright yeah yeah yeah big breaths whenever you're ready sorry by case of crepitations I think the eye is gonna and I think this obviously doesn't differ from edema it's probably all from the kidneys not from the the heart so mhmm like a nephrotic syndrome yeah because of the failure yeah after you see the urine so that makes sense yeah cool so have we have we explained the blood tests we've done things like that blood tests I know you've had some blood tests I test mhmm I take blood tests they show that the marker of a blood clot is high when you may have a blood clot in the lungs or in the leg although the coughing up of blood is concerning for a clot on the lungs dangerous 1 yes but no it's good no I have a clot we it's not that good I would say we need to look into why you have a clot here whether you have a clot here with a scan yes yes the kidneys make the scan more complicated we need to we need to make sure that you have dialysis after the scan otherwise the medicine that we give you during the scan will build up and hurt the kidneys more so I I my kidney I was yeah so about 4% mhmm 40% 4% yeah you're right yeah so at the moment probably the best thing to do is to bring you into hospital and keep you here dan and to see the kidney team and to sort it all out is that alright yeah yeah yeah yeah yeah in overnight yes yes it's for my self in the meantime we'll start you on some medicine to thin the blood which is an injection that you have to make sure that the clot doesn't get any worse and we keep a very close eye on you is that okay yeah yeah anything I've forgotten no any questions you have no good alright it was nice to meet you you guys good