Transcription - 20250927T 21-55.mp3

Next patient patricia risely 752372 hi patricia I'm doctor miller I'm 1 of the medical registrars it's nice to meet you we'll try not to disturb you just hoping to feel your pulses and have a listen to your chest okay so on general inspection she looks comfortable laid in bed unresponsive responsive to pain it's our staining on the fingers warm peripheries bounding pulses it sat on the monitor we're 74 with heart rate 140 his left lower zone caused crepitations to auscultation of a soft and non tender abdomen he's mild pitting peripheral oedema to the knees bilaterally needs some milk care tongue is dry blood pressure 80 over 54 with the ambulance cree with sats of 86% improving to sats of 96% with blood pressure of a 135 over 74 with some highly flares of oxygen sets some saline kcl in the department on just in case medications when she's had 2 days of priosine 1 dose of midazolam tep form has been completed by the ed team for advanced metastatic disease under palliative care not for escalation not for cpr yeah she's a lot isn't she we've got a little red I'll go it's alright so patricia risely 752372 75 year old lady metastatic small cell lung carcinoma histological diagnosis january 2025 current treatment palliative carboplatin + etoposide commenced 22 1 20 25 did not wish to proceed with further active oncological treatment when she spoke to the oncologist in march and has been now been referred for palliative care as contact from the rowcroft community palliative care team no treatment estimation plan in place investigation results blood cultures negative so far sunima 155 previously a 141 potassium 2.4 from previously 3.5 creatinine 61 from 53 inr 7.7 full blood count only on a 131 platelets a 128 neutrophils 12.81 alt 1 1 1 albumin 33 alp 2 7 4 bilirubin 68 protein 48 crp 87 urea 10.6 ast 126 most recent cross sectional imaging april 2025 I left superior mediastinal node reduced in volume left upper disease significantly reduced but left lower lobe nodule stable in appearance multiple small liver metastases more prominent than on the ct from march but appear reduced in volume compared to the pet scan subtle sclerotic changes at the site of some of the small bone metastases may represent a treatment response venous blood gas ph 7.49 lactate 5.1 glucose 5.9 impression most likely deterioration with left lower lobe pneumonia, profound electrolyte abnormalities and now unresponsive or responsive to pain on a background of known metastatic malignancy significant coagulopathy likely multifactorial with vitamin k deficiency and metastatic liver disease being contributing factors I agree with the a and e team that this is most likely to be a terminal admission and that we should provide palliative care I do note that she has a background of hypothyroidism and it will be given the electrolyte abnormalities it will be prudent to exclude thyrotoxic crisis or thyroid coma I should say so plan number 1 add on tsh number 2 scale 2 saturations and oxygen for comfort number 3 update next of kin number 4 just in case medications number 5 formal online tap form number 6 admission to any hospital side room for ongoing palliative care

Medical ST5 Miller Clerking

Presenting Complaint:
Decreased responsiveness

History of Presenting Complaint:
More unwell over 2 days, less oral intake, more drowsy

Acutely drowsy and less responsive with son this evening. Called ambulance. Hypoxic and hypotensive with crew.

Decision made to switch to palliative care by ED team soon after arrival.

Past Medical History:
• Metastatic small cell lung carcinoma - diagnosis January 2025, declined further active treatment March 2025
• Chronic obstructive pulmonary disease
• Rheumatoid arthritis
• Hip and knee OA
• Essential tremor
• Acquired hypothyroidism (1996)
• Peripheral vascular disease
• Osteopenia

Drug History:
• Morphine sulphate 10mg/5ml oral solution 2.5-5ml PO QDS PRN
• Paracetamol 1000mg PO PRN
• Celecoxib 100mg PO BD
• Lansoprazole 30mg PO OD
• Atorvastatin 40mg PO nocte
• Levothyroxine 100mcg PO OD
• Clonazepam 500mcg PO BD
• Sulfasalazine 500mg PO BD
• Primidone 50mg PO OD (morning) and 25mg PO OD (evening)
• TheiCal-D3 1000mg/880unit PO OD
• Escitalopram 20mg PO OD
• Trimbow inhaler 2 puffs BD via spacer
• Salamol inhaler 1-2 puffs QDS PRN

Allergy History:
NKDA

Social History:
Lives with son. Not coping well at home over last few months.

On Examination:
General Appearance: Comfortable lying in bed, responsive to pain only
Observations: HR 140, BP 135/74 (improved from 80/54), O2 sats 96% on high flow oxygen (previously 86% on air), feels hot to touch - febrile
• Cardiovascular: Bounding pulses, warm peripheries
• Respiratory: Bilateral Left > right lower zone coarse crepitations on auscultation
• Abdomen: Soft and non-tender
• Other: Staining on fingers, mild pitting peripheral oedema to knees bilaterally, dry tongue

Investigations:
• Blood cultures: Negative so far
• Sodium 155 (previously 141)
• Potassium 2.4 (previously 3.5)
• Creatinine 61 (previously 53)
• INR 7.7
• Haemoglobin 131
• Platelets 128
• Neutrophils 12.81
• ALT 111
• Albumin 33
• ALP 274
• Bilirubin 68
• Protein 48
• CRP 87
• Urea 10.6
• AST 126
• Venous blood gas: pH 7.49, lactate 5.1, glucose 5.9
• CT April 2025: Left superior mediastinal node reduced in volume, left upper disease significantly reduced, left lower lobe nodule stable, multiple small liver metastases more prominent than March but reduced compared to PET scan, subtle sclerotic changes at bone metastases sites suggesting treatment response

Impression:
Deterioration with likely left lower lobe pneumonia on background of metastatic small cell lung carcinoma
Profound electrolyte abnormalities, significant coagulopathy likely multifactorial with vitamin K deficiency and metastatic liver disease contributing

Management Plan:
1. Add on TSH to exclude thyrotoxic crisis/thyroid coma
2. Scale 2 oxygen saturations and oxygen therapy for comfort
3. Update next of kin - updated at bedside.
4. Just in case medications
5. TEP: WBC
6. Admission to hospital side room for ongoing palliative care
7. Any hospital side room

Summary

Investigations

Plans