So next patient patricia macy 1310303 so past medical history acquired hypothyroidism alcohol related liver cirrhosis <\n> Child pugh a at recent clinic appointment evidence of portal hypertension open brackets ogd june 2024 actually it's not an ogd from 2024 ogd november 2023 portal hypertensive gastropathy abstinent from alcohol at time of recent clinic appointment december 2024 previous decompensation with hospitalization in 2023 and then acquired hypothyroidism diverticular disease bilateral cataracts hypertension osteoarthritis brachial neuritis and then recent admission august to september 2025 were admitted with strep oralis on blood culture likely secondary to pelvic sidewall collection note that pelvic sidewall collection felt to be communicating with left hip for which avascular necrosis was mentioned bilateral avascular necrosis and left acetabular fracture on ct so she was admitted in august and september with that then she was discharged to community hospital for further rehabilitation where she was further diaries and rehabilitated and discharged on the 20 second of the ninth she where she'd completed a course of oral antibiotics and had poor mobility due to edema she was discharged to a nursing placement with a view to returning home until her edema was resolved and then she's now represented to hospital from the nursing home presented complaint is generally unwell and drowsy investigations inr 2.3 from 1.5 at the september ct head no acute intracranial hemorrhage generalized cerebral atrophy no skull fracture ct abdomen and pelvis with contrast large volume of situs no free intra abdominal gas liver irregularly in keeping with known cirrhosis recanalization of the umbilical vein in keeping with portal hypertension portal vein patent calculi in a thin walled gallbladder small bowel wall thickening may be related to portal enteropathy however there is a loop of poorly enhancing small bowel on the pelvis concerning for ischemia fecal loading in the rectum no gross colonic lesion bilateral avn at both femoral heads left pelvic cycle collection has increased in size minor right basal atelectasis widespread subcutaneous edema I note that this pelvic side or collection was drained on the august 29 ct guided the culture there was no growth but numerous white blood cells were seen other investigations full blood count hemoglobin 92 from 89 previously creatinine a 124 from baseline 45 aki 2 with potassium 5.8 and sodium 128 bilirubin 56 from 16 at the september albumin 22 from 20 amylase 51 crp 68 from 75 at the september urea 18.3 from 3 at the september social history I have lives with a husband no package of care no mobility aid ex smoker not drinking alcohol since 2023 but currently living in nursing home for rehabilitation what are phoenix doing terms of the microbiology alpha hemolytic strep strep auralis susceptible to keftriaxone on the august that's it ice cream have not been down because the s h o I think she been with you yeah fine getting funny about someone on that and I think we'll just wrap it up she's nice to you right we've all got s h s we've spoken to the icu consultant we've basically given half an hour a daughter asked him to see how he and then basically if he if he wakes up then he would go to the er if he doesn't then I'll get to the okay so we're just trying to get him to come back home yeah quick little up and down her numbers look horrible but I also don't wanna go rushing in with any fluids but I don't know whether now is the time for maybe a little bit yeah at least she's not she's not gonna run again I think I was gonna give her some more yeah I can't put her back to me she's probably she was you know 2 or 3 in a time limit and took on her diuresis I I agree she's got good normal rhinitis an element of her ascites might be misfortune in the vulvus that she's got okay because her liver is obviously back it's been a couple of years mhmm so the infection will depolmodate her liver but at the same time she it may be because of this you know pelvic infection the pelvis is driving a lot of this ascites so and probably that's what's he's gonna be sitting here and making his own stuff so yeah he's now woken up a little bit which is causing a new level of chaos and fun yeah numbers again not looking amazing but he's actually much more worried about that so he's probably due an 8 review over to at some. As well cool thank you very much great lovely oh 911 so in the investigation venous blood gas lactate 1.9 initially increasing to 3.3 on second gas sodium a 122 from a 124 hi it's patricia hello patricia hi patricia I'm rob 1 of the doctors nice to meet you can you hear me open your eyes can you open your eyes for me patricia can you squeeze my finger give me a squeeze paint 3 voice some sounds motor we're localizing pain fine nice seeing you from doctor richards yes yay great hello victoria hello the richards I'm alright 33 that's 98% so we're just patient at 16 blood pressure 105 over 61 yes so yes it is a fantastic story a very story yes so it was my own previous diagnosis so the hand neighbor that I had was that todd had said basically we're jaw thrusting which doctor would be good to no my day is no or even just to continue doing that for half an hour completely open up then it's gonna take my pc with I'll just come back with an ultrasound machine so on examination normal heart sounds bile basal crepitations to the mid zones pitting edema to the hips bilaterally abdomen firm and tender patient appears in pain just gonna see what I need bastorexis present private information from the ambulance crew well this morning when she woke up baseline gcs 15 no normal neurological deficit 12:30 refusing her meds it's not going to get normal self much less response take patient's blood sugar came back at 2.9 given glucagon by the crew no change to blood sugar and conveyed to ed may have spent a prolonged amount of time with blood glucose low impression decompensation in liver disease secondary to intra abdominal infection with pelvic cidal collection increasing in size + possible small bowel ischemia decompensated with ascites open brackets however much of this may be related to abdominal collection close brackets, encephalopathy but not bleeding aki 2 secondary to the above plan analgesia as appears in pain number 2 iv glucose number 3 human albumin solution and crystalloid resuscitation number 4 iv antibiotics guided by previous sensitivities number 5 pharmacological vte prophylaxis number 6 surgical review number 7 lactulose aiming bowels open 2 to 3 times a day number 8 alright serial you've got serial now we're still leaving plan ecg