Alright let's shoot all the lines of course do you have any pain in your chest no nothing good I'm rob I'm 1 the medical registrars the a and e consultant told me that you were sat out in a and e somewhere doing fine being treated for a chest infection yeah I did have chest pain and you're a bit slow on your on the monitor so they brought you in here and gave you a bit of medicine to speech up a bit yeah and do you feel any better well it's making us a bit better actually you were doing 20 before yeah now you're going 48 that's pretty good think nearly doubled exactly I think we've won and this is not gonna last forever so we just need to put you on something different to keep your heart rate at a nice level sometimes when salts in the blood are a bit funny in the context of an infection or when your body's fighting an infection you can get these slow heart rates yeah yeah so we just need to look at the underlying cause and I'll add on lots of tests to look for that and then just make you safe while we treat the infection make your heart rate to get better sometimes people have pacemakers for this kind of thing when the heart goes slow yeah so I wouldn't rule that out so having a pacemaker put in while you're in the midst just to make sure because it's quite dangerous thing to happen and having a little box in your chest that just keeps you ticking away may be a safe thing to do it's alright great and how are you feeling in terms of the infection have you got a cough or cold I I had a bit of better feel better oh I'm more better I thought he was having a stroke oh alright I really did he was talking gibberish gibberish when he was burning up he was just oh it's terrible oh I can recall that I was wearing a dosagem in bed with 2 duvets on and I'm still shivering alright so you're feeling really hot and cold and having fevers and how long he have you been having a fevers for well I went to bed early because he was watching no it suddenly came on during the night yeah just getting it on yeah well I've I've never done that because it's so freaking cold so during last night the night of the fourth going into the fifth yes the morning of the fifth yeah mhmm you felt you had fevers breath that's great yeah still concerned you've had shortness of breath yeah it comes and comes and goes obviously if I'm walking then it definitely you know comes on mhmm so how far could you walk normally I can't walk very far in the morning because I got intermittent before the presentation at moment okay and it it was out to say that he he has great pains oh and I I and I've I've told the the oral urologist had sort of looked at and I've had all the low down with the and that's the first step I've ever had yeah I'd rather take it at the same chance mean if I'll be if I'll be then you know and what's that that'll be the the old diner of it again you know dine dancer in maine but oh yeah that's fine that's cool because it's right at top of my door okay I've had this 1 done have you had a bypass before no you had an endarterectomy where you yeah you've done it yeah yeah and they did this 1 okay twice and I thought I'd broke up but this 1 I'm just doing it's been taking but I find a way to like move to the brain so how long how far could you walk before the intermittent claudication sets in not very far 5 20 meters yeah okay like you can walk down the length of this room kind of thing yeah yeah yeah and then you'll stop and rest mhmm I suppose and and it's very very short and and I think this is I get a shorter and shorter and in terms of your shortness of breath yeah how long how how will that affect you when you walk will that limit your ability to walk if I run a pill walk if you run a pill but the claudication will probably stop you first that first what exactly do you need to do it got handy actually really yeah because the pain sets in and then obviously shortness of breath yeah and then if you just sit down and wait for the the cramps going know I know it's going so I just sit down and wait for it oh you get short of breath when you run up a hill but do you get chest pain when you run up a hill well you said you might get shortness of breath when you run up a hill I'm imagining you running up a hill you're running stuff I can imagine that I'm running back in denver schools okay yeah fine alright so chest pain is not really a feature for you intermittent chest pain on activity it's the coordination that stops you first oh yeah well yeah it's like okay it does know because it's it's really really come on in it's really really restricted by the reason why it's important to get this heartbeat sorted out because if they're going to do this if you've got something wrong in it gareth they won't do it that's true yeah and and how long have you had this atrial fibrillation this irregular heartbeat for a long time no no just got back from portugal last month oh nice and he was rushing well it was it was so awful and they they went in and said copd chest infection the doctor said wait and see so anyway did all tests over and around and said you've got atrial fibrillation and that was in really did and what did they start you on in portugal no just give me peruse of mine obviously with that legs like when you yeah really really swollen yep at my feet and what else are they gonna take me apaxalone apaxalone very good that's fine and you're on the apixaban still I am yeah good and how long have you been taking the apixaban now whatever month about a month about a month back yeah yeah have you missed any doses over that month uh-huh good night that's just thinking about if we need 1 in the morning make the heart lung better morning good the list of meds he had yeah and of course we were in so much room in the rush to get into the ambulance but I left it on file and I hope we missed fine I'm quite sure I'd have to lift this up so let's get this real and this is for your leg this is for the heart I'm in my leg and it's open but I can see it's at the. And the the here increase really works on board but you were able to get to the airport well walk on well no I got wheelchair yeah yeah I got and I put it in special assistance good thing really you'd recommend it are you oh yeah that's fine oh yeah yeah I went on baby I on holiday with my 7 month old baby girl the other month our buddy brilliant would recommend skip all the keys he's great he is brilliant so I bet you have the same experience yeah yeah that's probably why we're so brilliant no no it's only the last couple of years it's only you throw 5 drugs a bit really okay can run a brisk lap on that too yeah I'll do a hard work we'll let you know if you can if you can yeah I'll drink much more and do you drink or smoke I drink yeah I drink have a bite every now and again or more than that what we got once a week don't we well it's weatherspoon lovely and then you stopped smoking back in 1984 both of us great and how long did you smoke for I smoked for about 16 years 16 years pack a day over that time oh yeah okay and the rest 40 a 40 a day day yes 60 no not 6 not 3 packs a day 2 packs a day for 16 years yeah no that's fine that's fine alright okay alright can I have a look at you do you yes you should stay in hospital stay in hospital tonight certainly the reasons are this this keeps you in without question people needing some oxygen to help you breathe and that could probably be a combination of your heart going slowly and the chest infection you some strong antibiotics to treat your chest infection you need to be in a safe place on a cardiac monitor so we can keep an eye on your heart rate give you more medicine to bring it up if it goes too slow and probably you're gonna need a drip for the next 24 hours to keep the heart rates in a safe space you'll be at least I now you'll be of course yeah we're not planning to send you home sorry no yeah I can go home and but I can't take responsibility you can't blame me for staying in hospital blame the oxygen I'm not that's what really you do I'm deflecting responsibility I can give you a hand if you need to just wanna listen to your back oh it's got a big breath in the middle of your mouth thank you okay have you had an x-ray of your chest yet yes wonderful you can rest back do you want me to do want to slide back so you'd more comfortable or do you me to sit you up a bit more gonna sit you up a bit more I'll just do a bit more more right yes no sugar to no sugar thank you screams had just a cake and some bread you didn't realize he was doing it so and you're already these things coming off there's no reflection on you burns been happening every time I go to the toilet I need to go to when you've got to take a 2 because of this bloody prostate no no prostate right no I've got the stenosis in my neck okay found out of stent a few years ago you got spinal stenosis yeah and they were looking about doing another pain alright no bad starting to affect my that's why so it's starting to affect your your bladder and bladder is it making you retain urine or anything when it's not before no because I've got tummy loads and mhmm things around get rid of that rid of that problem it's the other way around I mean actually you can't go well I don't angle but but it's not in people oh you go all the time yeah it's it's it sounds like having prolapse a lot oh and is the spinal stenosis definitely high up not low down no high up high up that wouldn't usually affect no bladder effects it can sometimes well sometimes your leg's been collapsing hasn't it has it yeah oh in that case stomach ache yeah yeah and that it might be affected because 1 I'm walking along the next minute I might come in I'm deaf well it would have been a bit of a stick it's just ghost the pancreas goes that's lovely thank you so much thank you I've got your cup of tea last thing we should talk about is about escalation about what we do if you were to get more unwell in hospital I speak to about this all my patients after they come into hospital from my perspective if you were in portugal last week you've got something clearly reversible that we should do everything to keep you going including shocking you jumping up and down your chest taking to intensive care if you were to get worse any do you thoughts about that no do you feel like that's not what you want no no that is what you want that's fine some people say they definitely don't want any of that oh no that's fine yeah oh that's fine I mean that's problems we have life and life don't we we've 5 grandchildren and no that's I'm not going down the dnl path or not so no good yeah no and I'm not suggesting it sometimes people will say I don't know what works I have to talk to everyone about yes but that's fine yeah okay I'm in your hands essentially good yeah bro we'll make you better don't worry thank you okay we'll keep a close eye on you here until your heart rate's consistently where it is at the moment in the forties that's I'm not sure that I I feel like this cycle that won't go quite quickly yeah that's alright I'm good at all now yeah that's good well that's a bit of a isn't it I'm gonna make you suffer just for a few minutes and just set it up to go every 5 minutes just so we can make sure when your blood but your blood pressure doesn't go down when your heart rate gets down alright he hasn't had his meds doctor by the way oh yeah the ones that you're prescribed yeah yeah they sent oh well that's fine I'll prescribe all of most of your regular medicines I might tinker with them do like to tinker with things okay but yeah I'll I'll make sure that everything is most of the things that you showed me will be on there so don't worry alright those should be all on my yeah yeah get them off the computer if I go home can I leave them with mhmm so yeah that'd be great for us if you see them I'll set the monitor up so it doesn't keep all the time so if we accept 37 and on those it will come all the how long have you put in what'd they say 1 30 pounds you're folk and you're here today yeah alright that's okay have a look at a video of everything I'll see you tomorrow thanks very much alright thanks for being here observations heart rate 37 saturation 97% on 12 blood pressure a 111 over 81 gareth williams 724400 investigations ecg initial ecg atrial fibrillation with a rate of 60 beats per minute subsequent ecg at 10 41 showing a rate of 35 in atrial fibrillation and another ecg likely following atropine with a rate of 43 investigations blood culture is negative so far covid 19 awaited inr 1.3 open brackets on apixaban close brackets <\n> Full blood count lymphopenia, monocytopenia, eosinopenia but no neutrophilia or raised white cell count <\n> Creatinine a 140 from baseline of circa 82 or a 101 so that's an aki lft is normal crp 29 urea 9.1 2 so impression you go through my run like you don't get food for something mhmm to investigations chest x-ray bilateral hazy lower zone opacification fluid in the fissure upper lobe diversion on examination heart sounds normal bibasal fine and spiritual crepitations pitting edema to the knees bilaterally abdomen distended and obese but soft and nontender impression is low respiratory tract infection aki atrial fibrillation with slow ventricular rate requiring atropine plan number 1 cardiac monitor number 2 iv antibiotics number 3 slow iv fluids for aki number 4 note he had a temperature of 38.5 overnight number 4 daily uni while on aki number 5 in per hour monitoring number 6 sputum mcns number 7 urine mcns number next if persistent bradycardia with adverse features than likely to require isoprenaline infusion number next escalation discussed for full escalation as reversible pathology currently