H065884 joint 4 anterior exam it's a problem oh lovely john hello my daddy me and I'm not your wife that's your wife me and john was friends until about 3 until about 4 are you gonna become friends again no I'm going now okay maybe tonight our love our lovely john's a very confused man he had a bum as you know it's sad it was clear but last well yesterday obviously yesterday when he fell as well a little bit over the last he has fallen a couple of times this year my neighbor managed to get him he came over but he couldn't lift him so he went in case he made it I'm okay good you don't need pain anywhere or anything like that alright I'm busy so which 1 is it you said you want a paper towel you want a paper towel what do you want evelyn do want I think that's or in charge what's the other 1 0 the wet wipe 1 you want have you had any pain john how's your head feeling not well no very nice more confused over the last few weeks that first time that 1 it's been it's been there for you give me that 1 please hi john I'm rob of the doctors nice to meet you has anyone told you where you are at the moment yeah I'm waiting to get yourself can't let me yeah oh no let's go to the office here you've got the paper towel let's have a little look at each other okay so a bit more busy yeah than normal yeah over the last few weeks is that right a bit you've been a bit more unsteady on his feet over the last few weeks yeah yeah is that fair to say yeah I I I thought about getting rid of my zimatrol okay because he uses his walking okay so he normally walks around with a walking stick yeah you live together in a house yes yeah with stairs well I'm still if now I've got that for him okay oh because he was he was struggling for ages he wouldn't give in mhmm and asked me you know what what things is she got wrong with him I thought it's such a wrong list quite often forget things on the computer do you know what I mean no I understand there's just so many things I've never thought of things to check on the computer that's fine but he's 91 that's what he thinks yeah unfortunately he's he's up but yeah yeah so yeah okay fuck it so he's doing but he's he's a little bit and he's not making sense but it's worse because since he's fallen off usually you know he's quite right right lucid mhmm yeah he's not he's a bit forgetful mhmm but then he's not too much as well you know very well get mhmm but you're not in your nineties as well are you yeah well I see this month like snatching yeah right okay he's just you know he's just not he's thinking about himself mhmm and that's been going on for a couple of weeks had okay then you're getting gradually worse to today mean well I think it's I think it's after he's had yeah absolutely and then or back his head and tell me about the circumstances around him falling over in pain I was in the I was in the living room at the house watching tv mhmm and I yeah and well it's you know she's screaming so I went and I tried to hold him up he wasn't everything he was feeling backwards and so I got hold of the belt this dressing gown holding up for summer for a little got hold of the 1 of the chairs actually that was there and I tried to maneuver him so he could sit on the chair like was he oh that he felt and took me with him he went down he hit the the armchair hit your armchair yeah side of it I think so on his feet over the last few weeks isn't most of the weaning goes on at night getting up to the toilet yeah but yeah he accidentally seems doing worse but he did have 1 he's had a sort of face drop 1 side oh I know but he put he raised both arms he got caught he raised both of his arms so this was not his time yeah and then he very quickly became quite lucid oh good right so I think it's a forbidden 1 yeah it's true although this 1 they looked at and they say that he didn't he has that 1 tell a 100% where someone's had an acute stroke he didn't have a stroke 3 weeks ago because we'd see that I can't tell 100 whether he satisfied himself with it'll the be an uncommon way to behave after a stroke you have trouble moving 1 part of their body as opposed to being able to move everything you're gonna have a quick listen to your chest is that alright take take some big breaths for me take some big breaths in and out can I see your eyes do you mind if I look at your eyes that okay the movement seems good just follow my finger looking at my finger good lord alright can you do some facial movements for me give me a big smile mhmm give me a big smile lovely that's great close your eyes up really tightly yep don't let me open them that's great blow out your cheeks yeah probably can you feel me touching you here here here can you feel me touching you all those places yeah good man that's fine feel me touching you on your legs or on your arms does anything feel different either side I hear you after you get any getting weird on the right 1 very good and you lift the other 1 up the same it's in your calf can you lift both of the legs up can you lift your left leg up yeah lift your left leg up good man keep it up yes it's very good lovely and the same on this side lift it up keep it up push me down into the bed that's great now with your hands like this like a boxer go be really strong don't let me move you be really strong go on be really strong great fine that's good really good okay yeah very good thank you so you're you're we've had some blood tests since he's been here and you've had a scan of your head the scan of your head is fine it doesn't show any injury to your brain or any bleeding around your brain which is good your blood tests show we raise markers of infection ever so slightly and there's always the possibility that you've got an infection somewhere which can make people very confused and have a fall so I suspect that may be what's gone on it's difficult to know where the infection is at the moment but you should have some antibiotics to treat it I'll add on a load of other tests to look for other causes of transient confusion and falls and we'll I suggest we just scan his bladder to make sure he hasn't got a big bladder full of weeks as that can sometimes make people quite confused okay good and they said it it was empty but he insisted that it wasn't he has that's fine and we'll get him to it again we'll have another 1 I certainly couldn't feel it he didn't like it wanted it yeah he tried it we'll keep a close eye on it yeah and well in fact is what we call a delirium it affects lots of people in hospital up to 60% really of people 60 in hospital with delirium okay and that we know that it's very common the majority of people it reverses even 30% of people stay a little bit confused for a bit there's a lot of physiological stress associated with being in hospital so you're not battling an infection or something like that and so that can affect the functioning of the brain this can just stay away so that's what I think is going on yeah that's you know we're treat the underlying cause and get him back to just so that we have a plan if what happens mhmm I understand you guys live together but it sounds like his mobility has been deteriorating and if he can't make it up a flight of stairs I would worry about what would happen if he's not really strong worried about that in a in a chair looking up he likes it himself yeah that's good up and turn it at the top so yeah so and we have an alarm as well watch oh that's good he falls over the bus yeah he can he got a spot walk yeah what does he do for a living he he was a customer service he does drink he just eats some wine so yeah I only buy because I don't drink ice yeah no thank you right yeah never smoked good stuff down to the back of his head he was rested he was cold water with it and he was a bit dry dry but but it's it's a bit messy even though what we expect yeah not what we expect will happen it may happen mhmm I know that when people are in this thing in their own peace the person that your heart stops is close to just that if he were to deteriorate over the course of days and weeks stop because he was so unwell don't think jumping it down or you don't think doing everything is the right thing to do is that okay no alright thank you do you think it's something to dilute maybe as well no a reaction poor guy no water yeah he must be very dehydrated got something to drink are you thirsty right he has been he thirsty thirsty yeah he does he does choke he just does he regularly he's drinking water over the last 3 weeks you know so you have a small little straw so paraffin and gruy and you take a little bit of the speech and language team they're the experts at making it swallowed to come and have a look and see so on examination edema to the mid shin bilaterally calves soft soft and nontender confused disorientated amt 4 0 out of 4 using words are not dysarthric however confused and delirious good power in all 4 limbs no cranial nerve palsy on brief examination as tolerated by patient heart sounds are normal chest anteriorly clear abdomen soft and nontender no percussable bladder however I do note he has significant symptoms of prostatism and has urinated slightly in the bed impression delirium of uncertain cause possibly secondary to infection may have had a stroke 3 weeks ago leading to decreased mobility, increased confusion yeah exactly, unsteadiness on feet and swallowing difficulties for 3 weeks as reported by wife plan number 1 admitting medicine number 2 confusion screened bloods number 3 chest x-ray number 4 msu number 5 septic screen including blood cultures number 6 consult review number 7 consider mri head to exclude recent stroke