So next patient is roger thomas alpha436514 86 year old man past medical history heart failure with atrial fibrillation benign prostatic hypertrophy hypertension barrett's esophagus gord ckd newly displaced myelodysplastic syndrome newly diagnosed myelodysplastic syndrome on regular transfusion and epo therapy program observation 24 on 4 l of oxygen saturated 96% blood pressure 120 over 63 pulse 104 per minute temperature 37.3 oxygen by nasal cannulae it won't arrive on our wash recent admission they will in july 2025 for approximately a month yeah yeah yeah once achieved already 2 arms of breath secondary to pneumonia leading to right middle and exact changes yeah positive received 3 days of paxlovid siadh 1.55 liter fluid restriction malignant type 6 sterna swabs positive for pseudomonas past medical history myelodysplastic syndrome transforming to aml diabeticulosis reviewed by the palliative care team during the admission and discharged from nursing home hello hello detective discussion outcomes of fast track discharge yay did do too well investigations pancytopenia neutrophils naught 0.9 hemoglobin 78 platelets 8 white cells 9.3 waiting for electrolytes liver profile and crp chest x-ray right middle and lower zone hazy opacification but with also left lower zone hazy opacification and worsened from previous social history lives in a nursing home ecg af with right ventricular response rate 115 beats per minute hello hi mister thomas oh hi mister thomas I'm doctor miller I'm 1 of the medical registrars nice to meet you how are you you okay how are you feeling well just sitting here just a bit cold it is chilly isn't it yeah I can get you another blanket if you like okay alright and other than that how do you feel well I feel better than I did when I came in right and not too bad you know better better than I was this morning when I pressed the button in there good so something something these done is make you feel better yeah and you've been feeling chesty in there sorry have you been feeling chesty no no no and so how did you feel when just because I'm on this oxygen mhmm and I just sort of and how did you feel when you pressed the button what were your symptoms my symptoms exactly were that I'd just been for a pee in the toilet and to get back to the toilet I had to catch hold of all the door handles bars and all sorts of things that they've got arranged there I see and then I just collapsed onto the bed and lay there trying to get my breath and then I press the button and here we are are you got have a cough at all or anything like that have I got a cough club a cough a cough clot a cough clot oh no no I haven't no no fine alright any pain passing water or going for a wee no no trouble good your has anyone explained to you what you've we found on our test so far yeah has anyone explained no your chest x-ray shows a chest infection on this right hand side yes same side that you had your previous chest infection but it looks worse than before oh you it looks like the antibiotics that we've given you made it better for a bit but you may have picked up another infection since then unfortunately oh your blood tests have started to come back and your blood counts are very low including the cells that fight infection and we know that you're at risk of that because of your myelodysplastic syndrome but they are particularly low which would predispose you quite considerably to infection and it will make any infection harder for you to fight off yeah so you're on some strong antibiotics to treat a chest infection at the moment yes I know there were some discussions about when you were in hospital last time about what you'd want moving forward knowing what's going on with your myelodysplastic syndrome and that your bone marrow isn't making the right cells and they don't think they're going to be able to do anything to make that better no from reading the documents from what happened last time you were sent home to the nursing home and the idea was that we'd give you some blood products if needed to keep your blood counts up which we can do but you don't need any of them at the moment which is good the question will be whether you want to keep coming back to hospital with these things obviously you're in the hospital now we're very happy to treat you but it's about what you want does that make sense yes it does I prefer a hospital to the nursing home that's fine if you can of course we can that's what we're here for if that's what you prefer then that's absolutely fine yeah obviously coming to hospital always runs the risk even for me of dying in hospital yeah and I think we have to accept that risk and if that's something that is tolerable to you some people would say that they definitely would never want to risk that and so they would rather stay at home whereas some people are not bothered about that no I think I prefer hospital that's fine well it sounds like you're in the right place then yes it does that's lovely and you're on some good strong treatment help us do is I I've arranged for an undertaker oh to call at the home at 10:00 on wednesday morning I see and obviously that's gonna be changed you may well I think it's likely you'll be in hospital then still yes yes okay so can somebody organize that yeah of course I'm sure we can we can speak to the home and make sure that's all sorted they can get in contact with this person and they can then come see you here if they want to it's walter parsons okay okay I I we've got a bit of time what's gonna happen to me now so you're in a and e having some intensive treatment yes and once you're stabilized you'll come to 1 of our medical wards and we'll continue to look after you there where are they getting anything to make you a bit warmer I'm gonna get you a blanket now yeah okay can I have a listen to your chest and then I'll get your blanket alright thank thank you sorry it's bit cold in here thanks doctor it's okay yeah the only other thing is that I've got about 1,300 odd pounds in the sleep at the nursing home a few people know about it so I'm not really bothered about it but I wouldn't mind getting my money back and there's other things as well which I require from of course from the nursing home do you have any family or anything like that that might want to go do you have any family that might want to go and get those things and bring them in no no okay none at all I see alright well we can speak to the staff in the nursing home they may be able to bring some of that up for you if you want to yes okay alright I just want all my property back from from there I understand was the nursing home okay were they okay in the nursing home did they look after you well in the nursing home not sure no I suppose they're alright but they weren't as good as the hospital I'm sorry to hear that we often think that people will get better care in nursing homes than they are the in last time I was here I was first in birchborn and then in brackham I see yeah we'll try and get you back there because it's nice to have a bit of continuity to see the same people again yeah I'll go get you a blanket and I'll get everything else sorted over or something pops or sneeze into or course I'll get so on examination right sided crest to the mid zone pitting edema to the thighs bilaterally heart sounds are normal fast regular pulses noted abdomen's often non tender pale in appearance impression right hospital acquired pneumonia neutropenia on bloods but significant immunocompromise at risk of atypical infections including fungal infections plan continue tazosin add antifungal cover add beta lactam to bloods hold vt prophylaxis given platelets of 8 and likely underlying platelet dysfunction transfuse 1 unit of packed red cells for hemoglobin of 78 moved to bracken or birchwood under care of hematology hematology referral observations right 101 saturation is 91% blood pressure 134 over 69