Transcription - 20250927T 22-27.mp3

186 I've got it yeah mhmm then still waiting for crp but everything else is slightly worse his aki is slightly worse and his platelets are 21 mhmm he's having a nosebleed at the moment oh which is he's had recurrent epistaxis secondary to thrombocytopenia thrombocytopenia but his platelets were sort of 35 40 and now they're 21 yeah otherwise he's okay really there's not a clear source of infection I've asked the nursing staff to catheterize him and he's on a fluid chart already yeah he's awaiting a chest x-ray but he he's he's comfortable he's not he's just annoyed about his nosebleed yeah of course and from the notes the previous conversation was not for platelet transfusion over the weekend unless severe bleeding yeah but then another note says really discuss with heme if platelets continue to drop into low 20s yeah exactly and in the context of bleeding think we should probably chat to them and say look he's bleeding now can we give him some platelets please yeah and that will hopefully fix his bleeding problem in this this blood count this full blood count is from 20 50 is that right yes yeah fine yeah so that was before he was bleeding is that is that fair to say I think he's been having an ocd all day oh not really okay fine so he hasn't dropped his hemoglobin so that's something good yeah and but his urea is coming up so yeah clearly some of that blood is going down into the into the gut yeah or maybe it's just his terrible aki yeah maybe it's gonna be maybe his he had aspirated any of it but his blood was clear mhmm but yeah okay and then and what are we gonna do about so in terms of so the bleeding we're gonna chat to hematology try and get him some platelets yeah the kidney function we're gonna monitor his input output and are we gonna give him a bit of fluid so he's currently having a liter of hartmann's mhmm over 10 hours yeah I was a bit concerned with his hfref that he's he's not edematous so his chest is clear yeah he's certainly biochemically dry isn't he yeah so shall we be a bit more a bit less homeopathic yep and should we give it over say 4 hours 4 hours yep and hopefully that will improve his renal function somewhat is he and he's making some wee yeah he's passing urine great good and we should just check that and monitor that and you know make sure we count how much thankfully potassium's come down so that's another good thing and then the other question was about the inflammatory markers and what we're do about that because the crp's doubled color mark ah it's not not enough is it what are we treating don't know really yeah it's a few days ago but there's no clear reason why I mean he clearly needs to be on some antibiotics clearly he's got an infection that crp 400 is not just coming from cancer we've sent some blood cultures which are negative we sent some poo which is negative we sent a urine which is negative so covid back in february so but we've but yeah so he sent so he doesn't have a urine infection and he doesn't have anything in his blood and how's the chest it's clear clear yeah fair and then we had a chest x-ray sorry we're just waiting for 1 okay fine so I guess we could have a look at that but I suspect that what we should do is cover him for a hospital acquired infection yep and often the sensible thing to do is give him tazosin to cover him for a hospital acquired pneumonia taz yeah as which will it has got good you know coverage to make sure that and also cover him reasonably well for an aspiration if you think that's what he's done as well yeah and we can see what the chest x-ray shows if it shows a big stonking pneumonia then we'll be right maybe we could send some more urine and make sure he hasn't got hasn't developed a urine infection as well yeah and then that should be that should be him shouldn't it we make him safe we'll put him on better antibiotics will and he should have a dose of that taz tonight yeah not just for tomorrow morning yeah yeah so discuss with him tabs urine cultures chest x-ray yeah great and the and the in power output monitoring yeah for the and yeah exactly perfect thank you thank you talk you soon bye

Issues:
1. Thrombocytopenia with active epistaxis
- Platelets dropped from 35-40 to 21
- Currently experiencing nosebleed
- Recurrent epistaxis secondary to thrombocytopenia
- Previous notes indicated not for platelet transfusion unless severe bleeding, but to discuss with haematology if platelets drop to low 20s

2. Acute kidney injury (AKI) - worsening
- Urea rising
- Patient biochemically dry
- Currently on 1 litre Hartmann's over 10 hours
- Still passing urine
- Potassium has improved

3. Raised inflammatory markers with unknown source of infection
- CRP doubled to 400
- Blood cultures negative
- Stool sample negative
- Urine sample negative
- Chest clinically clear
- Awaiting chest X-ray
- No clear source of infection identified

Background:
Patient has heart failure with reduced ejection fraction (HFrEF). Previous COVID infection in February. Patient is comfortable apart from being annoyed about nosebleed. Patient is not oedematous and chest remains clear. Haemoglobin stable despite epistaxis.

Impression:
1. Thrombocytopenia with active bleeding (epistaxis)
2. Acute kidney injury - worsening
3. Hospital-acquired infection of unknown source with raised inflammatory markers
4. Background HFrEF

Plan:
1. Contact haematology regarding platelet transfusion given active bleeding in context of platelets at 21
2. Increase fluid resuscitation - change Hartmann's to run over 4 hours instead of 10 hours
3. Catheterise patient and commence input/output monitoring with fluid chart
4. Commence tazocin tonight to cover hospital-acquired pneumonia and potential aspiration
5. Await chest X-ray results
6. Send repeat urine sample and cultures
7. Monitor renal function and electrolytes

Summary

Investigations

Plans