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 6 patricia reason hello hi I'm rob I'm 1 of the medical registrars nice to meet you how are you I'm just gonna nip out the phone oh okay alright you're okay yeah you're son is that is that right son yeah nice to meet you nice to meet you I've I've heard about from the a and e team a bit about what's been going on that she's been poorly for the last couple of days yeah yeah eating or drinking much bit rapidly yeah I'm sorry to date obviously all this mhmm well I'm sorry yeah and the team have been looking after her really well and making her very comfortable yeah I was just sending it yeah all good all right is there anything you need or anything you think she needs no I've just not gonna I'm alright I'm just being here with her really well can I do yeah okay yeah I might have to go at some? I've got a dog at home and need to walk in and catch a good feeding with a brother that needs feeding I understand yeah of course I know don't be able to stay for but you're more than welcome to stay with her as long as you're right I know yeah thanks yeah her husband's so kind okay alright well I'll leave you to this I didn't mean to interrupt I just wanted to introduce myself yes thank you she's coming to hospital which is why the a and e team have asked me to see her so we'll keep looking after her if she's here or if she meets 1 of our wards we'll keep looking after her there yeah of course okay I'm just sure we need alright okay she's got that along there I think certainly very poorly isn't she yeah so I'm picking on that suffering yeah of course yeah I don't think she seems very comfortable I don't think she's suffering no I think she is just comfortable now but she's suffered a lot up until now I'm sorry so so I've just had a very difficult time with the chemotherapy I was reading some of the letters yeah well to be honest she she handled it quite well the first 2 I think it was mhmm believe it or not I had a I started learning about herbal therapies in that last year and the year before and I heard that was really good almost as effective as chemo I'm not sure about that but I I made a sum up anyway mhmm she was taking it while she was having the chemo and she wasn't sick once right even fell out until a couple of weeks after the first 1 well but it was when that run out was after her third 1 and she was sick as sick as a dog then and she didn't want it anymore I just wondered if it was down to that because it seemed like the timing of it no you know nothing was gonna help us mhmm and there's only a very slight improvement on the scan with the with the chemotherapy that she had so yeah no I'm really yeah and but yeah it's quite aggressive cancer no certainly yeah I'm sorry mhmm okay alright I just wanna introduce myself no no no it's fine alright it's nice to meet you see you later impression most likely left lower zone pneumonia I've actually already done the impression so ignore that herniated strep and complaint generally unwell last 2 days poor oral intake and reduced consciousness level this evening

Medical ST5 Miller Clerking

Presenting Complaint:
Generally unwell

History of Presenting Complaint:
Patricia presented with a 2-day history of general deterioration and poor oral intake. Over the past 48 hours, she has become progressively more unwell with reduced consciousness level this evening. She is now responsive only to pain. This deterioration has occurred on a background of known metastatic small cell lung carcinoma diagnosed in January 2025. She commenced palliative carboplatin and etoposide on 22/01/25 but declined further active oncological treatment when reviewed by oncology in March 2025. She has since been referred for palliative care with involvement from the Rowcroft community palliative care team. Her son reports she had been eating and drinking very little over the past couple of days before this acute deterioration.

Past Medical History:
• Metastatic small cell lung carcinoma - histological diagnosis January 2025
• Hypothyroidism

Drug History:
Just in case medications administered:
• Hyoscine
• Midazolam (1 dose given)

Allergy History:
Unknown

Social History:
Lives with her husband. Has a son who is her main family contact. Son has caring responsibilities for pets at home. The family have found the chemotherapy journey very difficult, with the patient becoming very unwell after the third cycle when herbal supplements ran out.

On Examination:
General Appearance: Comfortable in bed, unresponsive except to pain
Observations: HR 140, BP ambulance crew 80/54 improving to 135/74 in department, O2 sats 86% improving to 96% on oxygen
• Cardiovascular: Warm peripheries, bounding pulses, mild pitting peripheral oedema to knees bilaterally
• Respiratory: Left lower zone coarse crepitations on auscultation
• Abdomen: Soft and non-tender
• Other: Nicotine staining on fingers, dry tongue

Investigations:
• Blood cultures: Negative so far
• Sodium: 155 (previously 141)
• Potassium: 2.4 (previously 3.5)
• Creatinine: 61 (from 53)
• INR: 7.7
• Hb: 131
• Platelets: 128
• Neutrophils: 12.81
• ALT: 111
• Albumin: 33
• ALP: 274
• Bilirubin: 68
• Total Protein: 48
• CRP: 87
• Urea: 10.6
• AST: 126
• Venous Blood Gas: pH 7.49, lactate 5.1, glucose 5.9
• CT Cross-sectional imaging (April 2025): Left superior mediastinal node reduced in volume, left upper lobe 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:
Left lower lobe pneumonia on background of metastatic small cell lung carcinoma
Differential Diagnoses: Thyrotoxic crisis given profound electrolyte abnormalities and hypothyroidism background
Significant coagulopathy likely multifactorial secondary to vitamin K deficiency and metastatic liver disease
Profound electrolyte abnormalities
Terminal admission requiring palliative care

Management Plan:
1. Scale oxygen to saturations for comfort
2. Add on TSH to exclude thyrotoxic crisis
3. Just in case medications continued
4. Update next of kin
5. Complete formal DNACPR form
6. Admission to hospital side room for ongoing palliative care
7. Any bed - palliative care focused
8. Not for CPR, not for escalation as per ED team assessment - palliative care approach

Summary

Investigations

Plans