It's the next patient michael lee 28902380 8 year old man presented complaints shortness of breath investigations troponin 62 from 48 venous blood gas ph 7.32 otherwise reassuring eco 2 7.2 8.5 on venous gases but 5.1 on what appears to be an arterial gas with sats of 83% but still appears to be normal renal function creatinine 78 from a baseline of 66 potassium of 5.4 inr 1.9 liver function test alp 2 1 9 chronically raised since august 2025 note background from recent fracture crp of 5 urea 11.7 from 6.5 full blood count hemoglobin 108 normocytosis and platelets 135 with neutrophilia chest x-ray poorly inspired portable film increased bronchovascular markings throughout without pleural effusions can move but is it going to work let me just recheck oh good yes ready yes I did it I did send you a note on this because I put you in another place but I already saw it ready I need second blow check the light in the yellow it was winston the brush tip yes and thank you for calling me otherwise I didn't do after the history left breast grade 2 invasive ductal carcinoma left mastectomy and axillary node clearance july 2025 concurrent bladder cancer progressive bony metastatic disease lesion in the left fifth rib posteriorly nuclear fusion in august recent admission on ainsley and teen ward during august 2025 following a right scapular blade fracture c 5 fracture of the left lamina and l 4 fracture of the right transverse process after falling backwards down 13 steps sustaining them these fractures he had conservative nonoperative management with analgesia ongoing cough for 2 weeks during that time doxycycline prescribed to cover for respiratory infections have you had lives with partner normally independent no mobility aid nonsmoker social drinker guide I will guide the patient's decision I'll take this episode 15 minutes yeah 15 minutes medication history atorvastatin I'll just copy it in atorvastatin 20 mg once a day memetizine 0.1% applied twice daily weightment when required paracetamol 1 g as required up to 4 times a day 20 mg once a day tamsulosin modified release 400 micrograms once a day bimatoprost 300 micrograms / timolol 5 mg per mil 1 drop in the morning dermol 500 when required bumetanide 1 mg in the morning rivaroxaban 20 mg once a day tadalafil 5 to 10 mg when required laxido 1 to 2 sachets twice per day having like a chat on this supper dose because it's observations temperature 36.6 heart rate 93 respiratory rate 22 blood pressure 157 over 81 saturation is 97% note that now so in the history of presenting complaint from the ed notes sudden onset of course crepitation is struggling with shortness of breath and breaks in hospital for rehabilitation following his recent admission low sats requiring oxygen no fevers no obvious aspiration event no chest pain or productive cough been managed for pulmonary edema no gtn furosemide for which she had a good response felt a lot better allergic to penicillin morphine and amitriptyline hello is it mr lee yes hello I'm doctor miller I'm 1 of the medical registrars it's nice to meet you I'll just wash my hands how are you I'm well do you feel better yes good I'm glad so what happened today tell me all about it not much not much you were in brixham hospital rehabilitating after your recent fall and lots of fractures by the sounds of it which sounds really nasty that's alright and then how did you feel about what did I I hear you felt suddenly short of breath is that right yeah I did and any other symptoms as well as feeling short of breath I just didn't feel well I didn't feel well the sister did what she could for me and realized I should see a doctor so she got me into to a rest mhmm yeah I think the the team in brixham asked for you to be transferred here which and then you've come into hospital and you've had some treatment to try and get some fluid off your chest yeah and does your breathing feel easier you're certainly needing a lot less oxygen than you were before yeah was you were needing 10 liters in the recess but now you're only needing 1 l yeah so that's much better isn't it this cough tell me about that when did you first notice that it was 3 days before I was out of breath fine so 3 days ago I started dropping yeah and what are you bringing up nothing much nothing fine just white stuff or just literally nothing literally nothing fine okay fair enough alright any fevers that you've noticed no there's a fever any pain in your chest no no weeing and pooing okay yeah good okay lost control say again lost control of it of weeing or pooing or both both goodness really after falling or in the home or in the community hospital I mean in the home I'm sorry we can often do that we can constipate people because you don't move around and then that can really make you lose control of things for how long say again how long would that happen if we treat the constipation it can often get better quite quickly yeah or not that it was a very it's the opposite it's the opposite often it can be weird I mean I don't know for certain I'll have a read over everything certainly the team when you were in hospital were concerned about constipation I think they treated you a little bit for that yeah in the context of everything that's going on I mean not moving around very much having a recent traumatic injury being on lots of things like painkillers that can bung you up yeah I lost a lot of weight now you already had all sorts of pain took a while to get get better but to get the right amount of pain go ahead and keep the pain away of course yeah I'm sorry alright other than being where I now you're in a and e I'm rob I'm 1 of the medical registrars torbay in torbay exactly yeah you were seen by the a and e doctor yeah and they've asked for you to come into hospital which is why I've come to see you just to make sure everything's sorted for you to come into hospital to stay with us here in torbay for a few days right just because you're needing a bit of oxygen and you'll need a bit more treatment to get some fluid off your chest okay okay yeah do you mind if I have a quick listen to your chest you mind no that's good thank you k gonna have a look at your legs do you mind that's it thank you so you got some chronic venous changes in your legs but there's no evidence of infection no peripheral edema really sorry very mild edema to the ankles okay can I see your tongue thank you that's great would you mind looking over to that corner of the room for me just look at this vein in your neck try and rest your neck down if that's okay can you please at the jawline okay great thank you can I touch your tongue any pain in your tummy at all no can I look at your tummy and touch it is that alright that's good thank you and how are you going for a wee do you have a catheter or anything like that no no nothing to get infected there you just wee alright okay and then these breaks in your bones you've got something here have you yep yep yeah that around doesn't move okay is that a long standing thing or is that new no that started when I was having a after biopsy for ah yes breast cancer for breast cancer I read about that yeah yeah so you have some this is a lymphedema dressing to stop it swelling up mhmm but the you've had trouble moving the left arm after the biopsy is that is that right yes mhmm okay and what kind of strength have you got at the moment none none can you give my hand a squeeze with your hand but I can't move it you can't move it lift it up no okay alright and before all of this drama with the falling over and breaking all of your bones where were you living you're living you're living with your partner is that right yes in a house or a flat my house in a house lovely and how were you were you you're pretty active yep yeah walking around independently by the sounds of it yeah not needing any help at home I go to the office barn and how's your partner are they well yeah she's well she's well okay that's great brilliant and drinking or smoking at all yeah I'm gonna go smoke that's fine you're a clean living kind of guy and what did you do for a living I was a roofing contractor a roofer yeah what kind of roofing did you do flat roofing flat roofing fine yeah sounds like you need to cough this stuff up do you want a tissue to try and cough it up no don't think I'll do a baby here at all so yeah you should we'd love to get a sample of it I'll ask them to give you a pot so we can tell a sample of whatever you cough up okay that'll be great just because well better out than in number 1 number 2 if we grow something it'll help us decide what antibiotics to give you if we think you've got a chest infection yeah yeah the only doctor started you on some tablet antibiotics and doxycycline which is probably a reasonable place to start mhmm to treat things so with okay are you on with this with the painkillers yeah yeah I won't change any of your painkillers okay well but I'll yeah to make sure you're not in I won't I won't make you in pain or anything like that we'll have a look at how your bowels are doing and see what comes out when we open them and see if we can get you feeling better from that perspective as well I wonder if this is overflow diarrhea probably is alright often this happens when we we bum people up with all these loads of opiate medications because of the pain you're in and things and you have did you have a collar at any? I did have a collar yeah and what's happening with that well I didn't like it fair enough it took it off and I found that it seemed to be alright without it great alright fine then good so you don't need it you don't wear the collar no wonderful k alright brilliant okay well I get everything sorted for you to come into hospital any questions or anything I've forgotten okay then lovely it was nice to meet you see you later do you want to turn the light off or are you happy like this I'm happy like that all right see you soon pulmonary edema improved with treatment plan add nt probnp + or - echocardiogram to blood test add probnp to blood test + or - echocardiogram number 2 continue regular furosemide number 3 input output monitoring number 4 sputum mcns if produces number 5 encourage expectoration number 6 wean oxygen is able and then back to community hospital to continue rehabilitation as soon as possible ecg atrial fibrillation with rate 86 beats per minute