So next patient is john nash 1284142 75 year old man past medical history lumbar spinal stenosis degenerative cervical myelopathy cll af ckd 3 hypertension type 2 diabetes previous decompression of spine for cord equina medications history are enclosed separately history of dental complaint discharged on the 2025 following a presentation to a and e with an episode of syncope and breathlessness full stop the patient had had increasing breathlessness for the past few months with 3 pillow orthopnea at this time he was investigated with a chest x-ray which demonstrated a large left sided pleural effusion with associated dependent collapse of a small of with associated with a collapse but also a small right sided effusion also noted he was planned for an echocardiogram and his furosemide was increased to 80 in the morning and 40 and was discharged to await a pleural clinic which I believe will have happened last week although unfortunately there aren't any letters about this pleural fluid aspirated on the '9 eighteenth and 90 on the september 18 gram strain negative sample culture negative cytopathology no malignant cells seen highlights criteria this is an exudative effusion investigations gretinin a 123 from a 108 with normal potassium and sodium alt 52 previously normal in june 2025 alp a 191 but this is chronically raised biliary been 26 1 was previously 8 crp a 146 from 74 urea 12 ast 59 from 28 full blood count neutrophilia monocytosis and significant lymphocytes in keeping with the diagnosis of cll recent nt probnp 2,600 no recent mri did not comment upon any biliary abnormality however unclear whether this would be imaged for other investigations chest x-ray today I hope I've included that the crp is a 146 from 74 x-ray chest demonstrates right basal consolidation and haziness but with left pleural effusion having significantly improved secondary to recent drainage but with persisting left basal collapse / effusion and right basal effusion information from paramedic sheet brainage worsening at home not eating and drinking some confused headbound sleeping more than usual called 1 1 1 mister nash is it mister miller from 1 of the medical registrars it's a pleasure to meet you sorry to see you in the hospital yeah do you mind if I turn the light on it might go incredibly bright yeah yeah so I'm driving me get that's nice where is it oh well it's nice to meet you how are you feeling not too bad too bad okay I had a read over everything I saw that you were here a couple of weeks ago and then you came back on the nineteenth to have your pleural effusion drained and you had 5 l drained from the left where the fluid was collapsing 1 a half 1 and a half fine someone wrote 5 but maybe they missed out on 1.5 okay that's good we have 1.5 liters drained off that left side it's gone to the laboratory there's no infective cells in it there's no sign of cancer in it where the fluid is coming from is difficult to say it looks as though it's being released by something as opposed to collecting because the heart's not working but I was keen to just examine you and see what's going on and try and work out what's going on and then since then you've been more poorly I understand yeah getting out of bed not feeling yourself yeah any cough or cold I'm I'm not coughing and bringing up a lot of you're bringing stuff up yeah when did that start after the drain 5 okay yeah so you're coughing bringing stuff up what color is the stuff that's coming up orange green sometimes white mhmm mhmm and any of the legs anything like that and your eyes look a bit junky are they sore yeah they're look I've got a lot of little torch here do you mind just looking up towards the ceiling points to your eyes a bit more your conjunctiva are lovely and clear and the eye's junky looks like you have blepharitis inflammation of the eyelids your conjunctiva are fine and the eyes themselves but your eyelids are inflamed and upset I'll give you some eye drops to make you feel better is that okay no I'm very fine thank you good looks of your chest ex I'll I'll examine you first before I tell you what's going on if you don't mind otherwise I'll spoil it for myself yeah what did you do for a living I want you but in the print uh-huh fine for like a newspaper no not not in those commercial printing commercial printing fine okay like signs and things like that yeah fine okay and you'd paint the signs or you'd fit or you'd work at the printers that printed them no I actually ran the presses you ran the presses correct yeah cool and when did you retire from that I'm making an assumption that you retired oh yeah I I'm not I've got my nice little payout at an early retirement well it's hard oh fine that's for about 4 mhmm but who lives at home with you wife your wife no not really how often do you guys get out the house once a week get it delivered or you go out yeah live in the cheppet job no oh no we'll see I don't know where that is I'm in the state oh it's oh fine yeah I know right yeah I know what you mean lovely fine yeah your shopping delivered how do you get around the house do you need have anything to help you or you just well when I was in the last I got in the mhmm you know we we like a zimmer frame yeah it's not very good it's okay but when you're on the carpet my lip sneeze forward right on the lips okay it was just lately that way oh that's annoying it is annoying I'm not I just so when did you start using the frame around the house like just after you came out of hospital 1 1 yeah once about in the last few weeks yeah before that how are you getting around the house just walking independently with a stick and when you and thinking about before you came into hospital last time how often were you getting out of the house then oh I got out yeah how many times is not much once a week or once yeah it's taken it's basically mhmm but I use it mhmm but lovely fine alright and how about stairs in your house do you manage them okay it's getting hard I bet it's getting harder and before all this breathing stuff started how was it just cough this up at all and then don't be polite just cough this stuff up get rid of it all all like must get it up need you need to expect your intake otherwise it'll build up in your chest and the infection will never get better bring it up it'll be fine I don't know good okay fine and do you drink or smoke I haven't smoked much mhmm it is still a little bit yeah fair enough I think most people did the first time really it went up anyhow mhmm and that was over the next time compression mhmm that was almost 3 4 cans per larder lovely best choice you've probably seen this stuff guinness for your anniversary oh no just really I'm not a guinness finger my son says you wanna feel good mhmm let you feel better yeah I was I have friends I I've been working on venice past and it's turned out nightmare have you brought it with you no oh got it he'll be waiting for you when you get back home yeah do you think your wife will drink it no she's right I was gonna say it is a heavy drink from london where about to london are you from east london northern ireland yeah east london yeah only 1 lessics bad little town yeah yeah I know I know worked down here for a while but you grew up in basil work yeah and did anyone help you at home do you have any family close by or anything well my eldest son is right grinchford is in grinchford here yeah but do your boys help you much always help you a little bit oh yes well when I I rub my spins up and you know get that much and what stops you from doing it yourself is it your spine is it the pain in your back it's the steps obviously your breathing is difficult over the last few weeks but I'm just trying to gauge what you were like before that do have any I mean I what stole that I feel bad for the last 3 me I'm worrying about the steps understandably but but okay and the operation test is that alright feel free to have as many coughs as you want I don't mind can I touch your tummy if you mind no you allergic to anything no water works all okay no pain passing water you're going been for some wheeze today I don't know why you're been for some wheeze today no I don't know good but there's no edema on your legs which is good your heart sounds lovely on your chest you sounds like you've got chest infection here uh-huh you've got a tiny recollection of the fluid on this side from what it sounds like and your chest x-ray looks like that as well the fluid collection is only tiny but the chest infection is what's caused your problems so you have pneumonia back in hospital with that you may have picked something up when you were here with us on your brief stay and I think we should cover you for strange bugs that exist in hospitals with strong antibiotics may have also picked it up at home maybe that the collection of fluid that you had was because of the developing chest infection possibly your you've had some blood tests which are fine your markers of infection are up but your kidneys and liver are all looking okay says no okay so I'll put you on some strong antibiotics I'll suspend your water tablets briefly because your kidneys are taken off anything else up we'd love to have a sample of it and we'll take a sample of also ask them to send a sample of the of your blood for the to the laboratory to make blood you're on some oxygen which is what keeps you in hospital 1 l but we need to get a bit better and stronger in order to get the oxygen off and get out of a lot of that will be trying to sit up straight and cough this stuff up because the secretions are a real problem aren't they like achy and flu y and things like that it must be it's tiring you know your body's working hard to fight this infection you for flu and covid it's unlikely you have it but it's going around a bit at the moment it'd be just good to make have you ever when people come into hospital it's important I think to talk about what would happen if things were to get worse have you spoken about resuscitation before and things like that or not have have you had any thoughts about it I think if it's I I don't know it's a question you know yeah of course no I'm yeah you can more than welcome to speak to anyone without it yeah I was what I was gonna say was that you have something clearly reversible I an infection in your chest I think it's entirely reasonable to treat that and to treat it on your chest as well and I think we'd be happy to do everything to treat that sometimes people have strong views about that they wouldn't want that but from my perspective I'd be happy to offer that yeah is that okay with you wonderful I'm not gonna impact you on that okay great I'll leave you be to get some rest you've got a few hours of rest yeah unless you have any questions for me or anything like that the the only question is I'll just yeah shall I help you sit up down the bed see you're not I don't know how tall you are you're probably back tall as me mhmm but your feet are on the bottom there's all this bed above you unused so you need to get your bum back to about here there are various ways we could try and do that if you like you could sit up more I could put my hands under your arms and we could I could help you shift shift up the bed say the bed is slippery isn't it it's awful other options I can get some hands and we'll lay you flatter and slide you off the bed okay would you rather do that yeah that'd be fine that's fine I'll ask for people to come and get ask I've got so could I have some more I've got crush here but I might wanna trace you from that spot I don't know what you wanna do yeah you see how I do water gave him a little bit yeah oh I wouldn't have yeah we'd love some we'd love some sputum but we'll we'll give you a pot to give us some yeah you wanna try shifting back quickly these are some socks they're present from the nhs oh are they they're kindness wanna try shifting up shifting your bum back ready ready or not really no no you can take it what do need to do so you don't know that long term heart attack sorry no you may not be oh yeah and what make the bed I can't make your bed any longer no the mattress is there I want you be shorter you need to be shorter you know I've come for a bit I can't make each script I think your legs need to be a bit less leg break what up is it just trying to make it a bit less like a the legs out we don't want the leg down I'll lay you down a bit more so you bend your knees through hold on there hold on and is the lower back completely flat and you slide up flat well trying to yes please please okay now you can get your hand up flat easily gravity on your side can we try that if you bend your legs not gonna feel good no you're gonna good gonna feel I'm like I'm getting to go good better brian do anything you did it all yourself I don't know I'm gonna stick it you just is that okay alright hold it you want me to lay you flat out no that would be a while right sure I'll able help you okay I'll put you wherever you want whatever makes you comfortable okay it was nice to meet you oh you you're fine yeah I'm not sure we could do anything else for you you've been in charge of family you've there were no cancer cells seen in the flu shown here here yeah infection and pneumonia same thing gonna have pneumonia you're need to address yeah fucking refilling now just for now while you're in the hospital with an after infection we restart it and you go out okay alright I'll come back to you in morning if you're stopping so they can't allow us time I've had the light to see if you sleep so on examination left basal left base decreased breath sounds right lower zone coarse crepitations heart sounds normal peripheral chronic venous change in the legs but no peripheral edema impression right basal pneumonia on background of recent hospitalization to treat for hospital associated pneumonia plan iv antibiotics number 2 hold furosemide as no current evidence of clinical overload and exudate in pleural fluid number 3 pleural team review of results to guide further investigations 3 number 4 in power output monitoring number next sputum mcns number next blood cultures