Roy stoffard 6 93622 69 year old gentleman history from the ambulance crew at 02:00 in the morning let dogs outside to go to the toilet upon returning inside to the kitchen wants to sit on his wheel stool for a brief rest stool gave way beneath him fed onto his bum unable to assist patient standing right investigations ecg difficult to interpret due to artifact likely atrial fibrillation with rapid ventricular response been treated with tests and gentamicin by the team in knee as well as some iv fluid this is because of hypotension at a blood pressure of 80 systolic blood pressure now is 95 systolic with a heart rate of 75 on the monitor saturation of 93% on 3 l of oxygen and respiratory of 15 investigations lft is normal creatinine a 164 from baseline of 110 it's aki 1 crp of 29 urea of 13.8 baseline of circa 10 ast normal hemoglobin a 116 load note chronic anemia since at least february 25 normalcytosis neutrophils 13.69 venous blood gas no acidosis blood culture is negative so far chest x-ray right basal hazy opacification ominant right carina carina possibly rotational no evidence of right sided pleural effusion possibly small left sided pleural effusion add to the plan hold bisoprolol given hypotension hold lisinopril aki suspend furosemide given hypotension add to the plan the aki bundle which is daily u and e while in aki input output monitoring urine dip add to the impression so impression is hypotension secondary to right community acquired pneumonia open brackets curb 65 score of 3 close brackets aki 1 long standing anemia of uncertain cause challenging fluid balance given clinical overload however persistent hypotension driven by sepsis likely to require diuresis following treatment of infection at the investigations nt probnp 1,102 from march 2025 that's investigations most recent h b a 1 c is 40 on september 30 could add that to the past medical history under his diabetes as well hi mister sebastian hi there I'm 1 of gastroenterology doctors yeah how are you how are you okay good how's your breathing feeling oh okay maybe with the oxygen I'm better you know good do you feel particularly short of breath at home not really now because I I don't know exactly what you know thing is I don't exactly self what you tell me yeah fair enough you know I heard you were going out to let the dogs out at about 2 in the morning is that right and then you got back and you were going for a rest and then fell onto the floor and couldn't get up is that right well no I was trying to sit on my my I've got a stool with wheels on it yeah which I use to to approach around the kitchen to clear my sounds nice yeah it is I didn't know you could fly yeah yeah yeah I tried to lean back onto it and it shot away yeah and I was shot down cool thing did you hurt yourself no not really it's just I can't get up I've got strength in the last few months I lost all strength in my body and fingers tingle mhmm really your fingers tingle yeah that's funny and in terms of all strength in your body you mean in terms of standing up and walking around yeah mhmm and you've been taking some tirzepatide I think the injection in the tummy yeah for the last few months around the same time yeah I mean they're new drugs but we don't really know what those are the side effects they might cause I could look I'll look into I'll do a big panel test to look for causes of muscle weakness check your thyroid levels your b 12 and folate levels your vitamin d just to see if there's anything we can replace to try and make you feel better yes from that perspective yeah and then obviously you're needing a bit of oxygen which is unusual for you because you wouldn't normally need that at home no and your x-ray looks like you might have a bit of a chest infection on that right hand side right so we suspect that may be way why you fell over because you were feeling weak because you had a chest infection yeah does that make sense yeah fine have you been coughing or or probably no no no are there any other symptoms at all any tummy pain trouble passing water painful passing water no bowels all okay bowels the the codimol as soon as you are yeah I still go twice a week okay so would you like something to have in the evening that keeps you going more regularly or not well I've got some lax laxidoses yeah yeah well the morax laxido yeah you could use some laxatives should take them but they taste really horrible yeah they do why don't you try some senna it works in a better way I think senna it works in a better way to counteract the effect of the codeine on the bowels because the codeine slows them down but the sena speeds them up whereas the lacido makes things wetter it's fine to make it wetter but it doesn't make it come out any quicker so if you're passing a nice normal stool but just not as often as you'd like probably selenium is the way to go I would say so I suggest we try that that's alright I have a look at you do you mind looking at your hands and listen to your chest yeah cool what's this wrist splint yeah it's a long standing thing with I think it's tendons tendons carpal tunnel or well no it's it's down here carpal tunnel is here isn't it yeah is it's true oh that's fine there but it I thought it was broken I had an x-ray a long while ago and they said there was no break mhmm but it just hurts and I when I put this on it doesn't hurt so much it doesn't hurt so much so after a while take it off again yeah fine alright fair enough and how about your legs how are they have they been swelling up or popped up anyway they've been they've been swelling up a bit more than they have done recently 1 looks bigger than the right 1 from my eye it always has done always has done yeah yeah good alright so that's not keeping changed and what's under this dressing on the left it's when I fell over like yesterday I was starting to get up you know moving my feet like that and I was to tore the skin off right perfect because the skin is so fragile around there mhmm of course and and when it tears it takes months to heal oh it does yeah absolutely months can you feel your feet well no not really not that 1 that one's okay that 1 is just totally numb given you're on the tizatide I'm guessing you've got diabetes 2 type 2 we usually use it for that then you've got any eye problems from the diabetes no I I get ripped up big chunks you do and they're all okay yeah yeah good I'm glad excellent gonna have a look at your legs if you like yeah we'll just press them just so you've got some chronic venous changes on both sides there's no signs of infection so that's good mild edema yeah up to the knees maybe slightly higher up to the thighs anything on this side yeah a little bit here too a little bit here yeah okay fine thank you can rest it down thank you and then can I have a listen to your front and back is that okay of course thank you just so you don't have to take anything off it's all good let me just have a listen take okay so I'm back okay just take rest whenever you're ready a bit of crepitation on that backhand side but nothing on the right so that's good lovely okay any pain in your tummy for me or anything like that can I touch your tummy briefly just to make sure she's not tender nice that's fine it's been a huge we've popped it good I'm glad right so given the results on your blood test we see signs of infection and signs that you're slightly dehydrated on the blood test yes so we've given you a bit of fluid although you probably have got a bit too much fluid on board given you got a bit of swelling on your legs making your blood pressure better is the right thing in the first instance yeah so you've had that you've had some strong antibiotics and I'll continue some strong antibiotics to treat a chest infection yes once you're off the oxygen we can get you out of hospital essentially okay but until that happens we need to keep you on some antibiotics to treat a chest infection if you're able to walk around and move as much as you can that'll help your breathing yeah help your your it's a little bit pink help your oxygen levels get better yeah and then we it's I'll stop your a few of your medicines because your kidneys are taking a bit of a hit with the dehydration yeah so I'll tinker with your medicines a bit we'll try and restart them all before you get out of hospital okay does that make sense can I still have the painkillers yeah the codeine yes yeah I'll make sure they're on your chart good thank you and I'll start you on a laxative to go alongside the codeine oh lovely yeah lovely alright any questions or anything I forgot no it's great thank you very much and I should have asked who do you live at home with wife your wife lovely and any pets any birds yeah 2 dogs 2 dogs but no birds no no no oh no no no no no that's fine do you drink or smoke no I used to smoke years ago and drink no drink no fine how long do you smoke for oh god from the age of 16 through to 55 mhmm yeah so about 40 years yep and how many did you smoke for that time roll ups mhmm on a on a bad day 30 to 40 okay fine alright it's yeah 60 pack years fine alright at its worst okay that's good to know thank you very much it was nice to meet you you're welcome see you later