Okay yeah it's not very it's not very nice richard pastewski p a s t e w s k I 1 0 2 7 2 3 investigations chest x-ray extensive interstitial pulmonary edema ct head old infarct in the left thalamus no acute intracranial abnormality chronic sinusitis okay okay right right transverse and sigmoid sinus appears dense venous sinus thrombosis cannot be ruled out ct venogram would help clarify troponin a hundred and 12 and 249 creatinine 88 at baseline remainder of electrolytes normal urea 6.7 full blood count normal liver function tests normal apart from a hemolyzed alt but don't worry crp 2 advise my email see you're not gonna read the third blood gas normal recent urine creatinine ratio albumin creatinine ratio naught 0.7 very low urinary creatinine acr may be inaccurate observations blood pressure a 179 over 93 initially with temperature 36.1 pulse 82 saturation is 94% on air it works well blood pressure 184 over 95 later yeah yeah in that way yeah oh not yet but see what they say alright man no worries alright see you let me know when they when they reply what they tell you alright that's good leave it in 5 hours oh shall we say yeah no chest pain no chest pain at any time no but you had shortness of breath is that right yeah mhmm yeah little bit of shortness of breath and what was really bugging my asthma was this headache headache but it felt as if it was like here no you've burned your ears around to the back of your hair but not at the top not the normal not like a headache that you might get when you're a bit stressed or when you try out or dirsty and that's gone okay good it really felt as if I had a a near infection you know it was touching my head over there we've scanned your head which looks fine yeah the consultant looked at the scan this morning and said that there's the possibility of a tiny area which looks a little bit dense on the scan right it may be that there's a clot in 1 of the veins in your head and that could cause your symptoms I can't tell you that for certain no it looks like there may be the slight possibility of that so we should do another type of scan a ct venogram where you have some contrast in the veins of that to see whether any of those are blocked because that can cause high blood pressure and it could cause a high troponin as well it can sometimes cause ecg changes yeah it'd be worth excluding all of that before you rush down the heart yeah okay that's fine but I think it sounds like you know from the heart perspective there's a good plan to keep things covered yeah alright and in terms of other symptoms you've had the headache when did it start it started sort of tea time yesterday yeah really bad like just before I come in mhmm right and then then did you sorry go ahead it was like I won't say all night all night this morning I think it was a couple of aspirin yeah yeah you had a couple of aspirin yeah mostly for your heart not for your head mhmm like another dual purpose oh yeah but it's gone good cool guys I wanna keep it away yeah of course because it was just really uncomfortable was just somebody who was going like this all the time and course they sleep yeah lonely not good and any rim weakness tingling in any part of your body no neurological symptoms no nothing like that legs no great and so forth okay nothing at all fine no right and in terms of the shortness of breath when did that start yeah that started I would say my partner who's on her way in with clothes and toilet all of your stuff you need your makeup oh yeah and I started lipstick and so forth right here and yeah it it started yesterday so they gave it at around the same time or after the headache but then got you know got worse yeah a little bit worse but if if I was lucky I am now it was it wasn't too bad mhmm as soon as I got got up or whatever it was totally different yeah it was worse yeah okay would would you would expect it any other too big at all no okay I'm quite surprised about this heart malarkey yeah because no pain whatsoever you don't have diabetes do you have high blood pressure but nothing else like that do you smoke no no have you ever smoked yeah when I was around I smoked for behind the bike sheds at school kind of thing yeah you know in a few years after you were old 5 years after you smoked before yeah have you been back to the age of that time yeah yeah yeah that's where I've been for like 50 years and how about alcohol do you drink yeah normally I would drink every time yeah and have you been here yesterday or more than that couple of cans couple of with with the cans the 500 mil cans no the the 330 mil cans yeah mhmm yeah yeah and you have a couple of those in the evening yeah right so with 1 unit and another medic thing and the funny thing was that I yesterday because it was sunday we went down to our local pub I had to stand there came home and had my tea right came home and had my tea and and a sweet nothing oh not not at home yeah and fine absolutely fine I I didn't go you you you you what was that or some something like that but nothing at all and with the shortness of breath have noticed any cough fever anything like that no I can't stand again just had everybody else you bring nothing because no no great do you mind if I examine you quickly do you mind let's bring my hands somewhere okay so you've got crepitations to get me to say that's fine you can rest back where'd get your lovely town from we went to I think it's not yet no it's not so long we to this is what I'm talking about the comp of lovely it's been a long time it's a a been time we keep going back why wouldn't we yeah so no peripheral edema so we're be to stop here great I've just chest your reflexes in the power of your arms that alright yeah do this like a chicken be really strong okay I'm gonna take 1 yes be really strong don't have any lesions alright just be really strong yeah that's great good alright now I've got hands like this like very good that's good can you turn it great arms like this don't be really strong don't let me move you that's great now arms out like this don't let me push your fingers together let me push push your fingers together done with your little finger that's great don't let me pull them apart that's lovely I'll just test the reflexes when your arms are on alright relax on I've got it I won't drop it don't worry I will I won't drop it trust me I've got it oh no it's still holding on it's just 1 month I know it's not I've got it you can grab onto me for that you're a mistrustful man that's why I respect that that's better you're building trust that's good do you have a back just check the sensation in your arm feel me touching here yes here yep on your thumb yeah and on your middle finger yes yeah that's great yeah just test your coordination put your hand out in front of you like this give it a tap lift your hand up turn it over put it down again up over down up over it down now do that as fast as you can good man and how about the other side good man that's great well okay just do the same on your legs if that's okay yep okay you're still yeah good luck you're gonna push me into the bed with this stick going to the leg okay good and on this side push me into the bed that's great lift this leg up good man and lift this leg up can you bend your knees up for me yeah that's great kick me up that's really good that's great so take your legs back down and push down a little like a pedal and like a pedal and pull me up towards your head let's pull up just testing your reflexes have you seen his ct head result have you seen his ct head result oh so yeah so it's normal wasn't it sorry it's normal but the radiologist put an addendum on saying that there was the potential of a venous sinus thrombosis do you see I'm not seeing that bit no it's fine you might be sick because they put on late this morning I just saw it too okay I guess sometimes you see ecg changes in the context of venous sinus thrombosis very rarely and obviously the head is the presenting shall we switch let's let's leave it as it is at the moment but should we do venogram I'll put them a ct venogram to look for whether there's anything going on there I think in the context of anything you think with the progressive signs on the ecg and the troponin it seems like the number 1 differential is that of but the second bit of the second differential I guess would be weird things going on with an oocyte thrombosis I probably wish that's good because he's known as an easy to do a ct venogram and a bit advanced warning I think so should we do that before he comes over I was going to say just shall we clarify the matter so a ct venogram a venogram scan okay I'll write that in just so you don't yeah no that's great can't you be telling me that because I would have done exactly that yeah we've always freshened to bed so I'm trying to be helpful no but we'll take you out swing around to the scanner to the scanner before okay perfect so just tick on the bottom of your foot sorry and on the other side that's good can I see this side again sorry that's great well done you your your nerves are all fine in your arms and legs how about your face yeah that's fine I'll ask you I'll ask you some funny things if that's alright yeah so any problem with your sense of smell no no that's fine can you see everything okay can you move my bag yeah never can you move my eyes that's great that's me so I'll just ask you to cover up 1 of your eyes if that's okay can you put my finger over here yeah try to put it over there my lovely face exactly can you see my finger over here yes and here yes now swap sides for me right can you see my finger here yes here yes here yes and here yes yep and you still can see it from the periphery of your vision just here yes yeah I can hear that that's fine I'll ask you to do some finger movements now so just keep following my finger with your eyes and that's fine for you girl just put my hand on your chin don't worry you're doing great okay then in the extremes of vision I know it's a little uncomfortable just try and keep a little bit of eye on my finger that's great and on this side try and keep your eye on my that's lovely so that's asking you to do some facial movements can you pop out your cheeks yeah it's great can you lift up your eyebrows no surprise can you crunch up your eyes really tightly don't radiate you touch them here that's great thank you that's all sorted for you nerves are all fine they'll just scan you out and make sure there's no clots in the vein in your head just to make sure that isn't causing your symptoms and everything because sometimes weird things can happen when you've got a weak dot on your head can you get high blood pressure like this you can get ecg changes you can even put that blood test marker up of the troponin in the blood so just to make sure that's not the case that's not the case but if that isn't the case then we'll move towards the heart stuff alright full speed okay okay yeah well I'll put this scampi in okay alright let's see you too I just have staped you yeah what a crazy sink sorry I'll get you in your blanket no yeah what well not sure not sure I feel bad I'll have to I'll get you in a little bit sure so impression to exclude venous sinus thrombosis however acs is also a strong possibility plan number 1 ct venogram number 2 continue acs management for now number 3 regular medicines number 4 await results of ct before determining fondaparinux versus alternative anticoagulation number 5 ccu bed if ctv in the gram negative number 6 cardiac monitor number 7 monitor hypertension