So mervyn hawkins 089585 presenting complaint fall generally unwell history of presenting complaint admitted to torbay under the care of acute medicine 09/17/2025 treated for pneumonia and constipation found to have an aki pneumonia and constipation resolved treatment aki failed to respond to treatment for a prerenal aki and catheter and a renal ultrasound demonstrated an obstructing renal calculus in the left ureter as well as multiple enlarged lymph nodes full stop subsequently transferred to for a left sided nephrostomy on the 20 eighth of the ninth and he returned to torbay on the 2025 full stop during his stay in torbay he was taken back to theater on the eighth and the tenth for potential lithotripsy and stenting however stone could not be visualized in the ureter subsequent ct showed the stone was in the left kidney so he was referred for external shockwave lithotripsy full stop preoperatively he developed atrial fibrillation and he was started on apixaban with plan for cardiology review as an outpatient <\n\n> Also found to have multiple lymph nodes above and below the diaphragm which has been discussed at hematology mdt on the october 15 who feel that the lymph nodes are not likely to be significant and the splenomegaly has known clinically already for active monitoring past medical history jak2 positive polycythemia ruby vera 02/2009 left common femoral dvt 2000 and 9 on warfarin until 2020 hips inferolateral mi 2009 and inferior stemi 20 20 progression to myelofibrosis 2023 igg lambda monoclonal gammopathy of unknown significance or mgus 2023 82 year old man discharged with plan for external shock with methotrypsin with nephrostomy in situ then represents earlier today 3 days following a fall and found to be hyperkalemic on blood tests investigations creatinine 227 from 96 at baseline potassium 8.1 initially improving to 6.6 with several rounds of shifting therapy ct urinary tract left nephrostomy in situ 8 x 7 x 4 mm stone in the left mid ureter but no hydronephrosis 2 tiny nonobstructive calcicocele stones in an inferior left renal calyx unchanged right kidney splenomegaly has performed a small hernia reminder is unremarkable left hip prosthesis in situ no aggressive bony lesion urea 19.9 from 7.2 chest x-ray no confluent consolidation on lobar collapse a lfts alt a 150 from 18 alp 225 from a 140 total protein 84 from 68 troponin t 60 full blood count hemoglobin a 110 platelets 561 neutrophils 12.68 mla 72 crp 19 previously 25 unrecently discharged ast 146 from 24 ct urinary tract on the 10/12/2025 left sided nephrostomy in situ pigtail appears to be located mostly in the renal cortex coronation with nephrostomy output advised 3 small nonobstructive calculi renal stones are seen in the lower pole of the left kidney no radio dense calculi seen in either the ureter or the urinary bladder left distal ureter cannot be interrogated given the significant streak artifact from the left hip implant 3 nonobstructive calc calyceal renal stones seen in the left lower renal pole no evidence of ureteric or bladder calculi and ct thorax abdomen and pelvis september 2025 enlarged mediastinal hilar nodes 7 mm subpleural nodule in the right lower lobe no acute fracture or dissected bone lesion obstructing left ureteral calculus splenomegaly with area of splenic infarction and multiple small hyper attenuating splenic lesions mediastinal hilar lymphadenopathy borderline para aortic lymphadenopathy top differential will be lymphoma this is juliet most recent potassium 6.6 on blood gas at 3 38 and potassium 6.6 initial ecg ventricular rate of 42 prolonged preoperative cardiac subsequent ecg demonstrating sinus rhythm with first degree av block at much improved rate following calcium gluconate absent p waves initially however these have now improved following treatment hi marvin hello I'm rob 1 of the doctors hi marvin sorry it's just early I'm rob 1 of the medical doctors nice to see you here I see you've been in and out of hospital recently I was just reading all about it yeah no no sorry about that I went to exiturf are all jaunt and now back into a bay again after a brief. At home is that right yeah yeah and what brings you in this time what's the number 1 thing can I get a treat is that right no that's okay not sure 1 very well yesterday morning mhmm and what were you not well yesterday I couldn't sleep at all all night I hardly breathe what stops you breathing oh so does my oh this is your chest let me pull your tummy and have a look at it is that alright have you got any pain in your tummy no no pain no I'm sure last name on this left hand side no they're coming in is it draining alright that has some weed coming out it isn't really when did you last empty that bag I I've haven't emptied it yeah I've emptied it people have emptied it fine when is the last time anyone else emptied it I can't remember okay have you been winging since you got here pardon have you been winging since you got here last year several you're using buckles yeah yeah lovely alright that's fine yeah I'll have a look and see how much has been coming out and things like that can I see your tongue do you mind yeah just very nice lovely that's fine nice and moist that's good do you want to look over to there and I'll have a look at your this vein your neck try and rush your head back if you can that's lovely your gvp's lovely that's good fine alright I need to it's a bit of a mystery what's causing all of this high potassium malarkey but the important thing is that we've made it a bit better we could probably make it a little bit better again yeah and we'll try and do our best to make it completely normal as best we can well don't know I I got it yesterday morning at home so I was I was real bad there yeah of course let me have a look at all of your charts and things like that and all of the investigations we've done I'll have a chat with my surgical colleagues and try and work out what's going on there you need to stay in hospital to work out what's causing this dangerous high potassium level because your heart was in a bad way when you came in and the potassium when the potassium levels are high it can cause heart trouble so it's best to be in hospital until we've worked out what's caused this high potassium and made it better okay mhmm alright let me have a look at everything okay nice to meet you heart sounds 1 and 2 but with a pansystolic nerve lattice in the mitral area clear lung versus bilateral moist mucus bundles jvp at 2 fingers abdomen soft and on tendon left laparotomy in situ draining clear urine into a bag so 2 rounds of shifting therapy have been given far note input and output so input so input 1,644 milliliters output 355 mils of urine 217 of nephrostomy output and he should actually add 1 2 3 rounds of shifting therapy so had lokelma tazosin social history lives with wife usually independent add to the past medical history jehovah's witness medication history apixaban 5 mg twice a day round pill 2.5 mg once a on on examination we've got moist mucous membranes fine impression is hyperkalemia with ecg changes of unclear cause pattern of blood tests suggests possibility of obstructed neuropathy however nephrostomy appears to be working albeit slowly plan number 1 send nephrostomy urine for urinary electrolytes <\n> Number 2 hold ramipril <\n> Number 3 continue hyperkalemia treatment and monitor potassium in <\n> Number 4 continue nakalma <\n> Number 5 strict empowerment monitoring <\n> Number 6 pharmacological vt prophylaxis <\n> Number 7 if potassium remains high on bloods then consider renal input due to persistent hyperkalemia of unclear cause