So next patient is george clay 1471002 80 year old gentleman investigations hemoglobin 87 neutrophil 7.44 with mono cytopenia chest x-ray has been reported as patchy airspace consolidation within the right and left middle zones which could be consistent with widespread infection no pleural effusion venous blood gas ph 7.41 otherwise reassuring base excess - 7.1 metabolic acidosis with respiratory likely secondary to hyperchloremia and lactate owen man hello how are you I'm rob I'm 1 of the medical doctors I'm 1 the medical registrars of common who have you who have you brought with you I hear you're on holiday is that right it's a lovely tour there yes wonderful when did you get down here when did you get down here yesterday wednesday yeah thursday excuse me that was yesterday no it is thursday yeah yeah you got down here on wednesday and how did you get down you drove sorry did you drive down yeah think I oh my eyes weren't friendly yeah yeah because something's really triggered me in here sorry you drove down here understand is that right and were you feeling all right before you set off I'm feeling fine good were you feeling okay before you set off on coach run came on coach yeah on a coach ride yeah 2 miles around before you that's good fine okay great and where how far was the coach ride about 300 miles came from leicester from leicester fine yeah okay alright and so you come down on the coach from leicester you set off the day before yesterday or did you stay overnight or is it all during the day on wednesday yeah so you drove all day wednesday yeah and then you got down here yeah and then you felt poorly is that right yeah well tell me about it well the night before at home he'd been coughing okay and we it was like this shall we go shall we die and then in the morning bill had said actually I feel alright now I think we'll go okay so we did I haven't felt terribly good nothing like that I've been tired mhmm for how long have you felt tired like say 30 years I've felt tired during the day because I've not slept very well in the evening I see fine okay the night before you set off yeah you're excited because you're going on holiday well since we back your bags since we've been here as well mhmm but I've I've been finding that occurring mhmm most of the time I see yeah at home as well and so you were coughing at home is that is that right yeah yeah we've he had a bit of a cold between us nothing noticed not a lot but he had been coughing that night before we came away but in the but he's not been coughing in the day only midnight when he lays down okay yeah interesting so yeah but he's not been coughing in the affect well he's not 1 no excellent when did we get when did you get 1 there you go so he was coughing last night as well so we ended up I had no pillows and he had the ball yeah to try and sit him up and you had some breakfast this morning didn't you yeah and you had some soup at lunchtime mhmm but he was being very lethargic and not tired and have you had any fevers well that's a good question because I tend to because he's diabetic and I record everything well he's on a sensor so he's got this is exactly what I need could you follow me around yeah on wednesday he had a temperature of and that was half past 5 in the morning at a temperature of 37 so not crazy no no nothing nothing's been crazy 37.6 37.9 low grade kind of free delivery kind of stuff so every time I've looked on Google and just seen where yeah how difficult that was not above 38 but close to the line yeah you know 5pm on wednesday when we arrived it was 37 which I didn't think was too bad not too bad I called thursday in the night 37.1 so a little bit 20 past 5 37.5 mhmm and 7am 37.1 but today twice he's just been down to 6.2 in our goal nothing we haven't managed there nothing if he's been fighting an infection he's gone over it yeah fine and then unfortunately not he has had low blood pressure 100 systolic or so okay I read that side down side I can't my own writing but I read your card so doctors don't write properly is the known fact no 1 ever taught me how libre brilliant so we've followed that all the way and what kind of diabetes do you have because I don't have any records for you because you've obviously not been to our hospital for or in our area too but he's had it for 20 years and you take insulin he's on long acting insulin insulin tard you see the tard yeah and then and then these quick vaccine pens there lovely and then you take the true wrapper brilliant yeah and these are all your medicines yes and how many units of the insuletard do you take oh it's all here 5 yeah so yeah have 20 with his breakfast of insuletard or insuletard yeah and then 4 units of that of the apprapid or the I should say the trurapid yeah yeah trurapid and then you eat evening he has 10 if he has 4 again and then a bit of 4 but nothing and nothing else just his quick acting a little bit if needed depending on what we're doing alright and nothing at at lunchtime no okay that's fine no good good and you take the lansoprazole finasteride furosemide metformin bisoprolol cocodone and take another fruzemide at lunch yes and do you know the dose of any of the shots that lansoprazole the fruzemide it's difficult when it's in the dusted box isn't it yeah because I've written all this myself so bill did write so little I don't know I don't know if he's written the actual no don't think he has no he was just looking for why that's doctors yes yeah so why was taking it yeah and he asked well he's died been diagnosed with dementia and and shall I have the other 1 you have to look no it's fine it sounds like it yeah fine fine that's that's okay no that sounds fine yeah so he's got a diagnosis of both of those okay and then with the prostate he's got a prostatic enlargement yes he hasn't got cancer no cancer that's been checked and the metformin is from a type 2 diabetes disease yes and that's been reduced lately because of I can't remember exactly why but he used to be on 2 but now he's only on 1 to work with yourself to to your pharmacy or your gp I might have 5 minutes to do it and then my daughter-in-law is a pharmacist okay and she keeps us in check had told us she had no diagnosis yeah she would have been a call that would be really helpful yeah because it's gonna be difficult to start all of these back without any of the right injections because she sometimes writes an email to our pharmacist because she keeps a close eye on them great and she's a team leader for a group of pharmacists okay she's she knows what she's talking and then he takes warfarin as well at the minute that was high last week he's on range 2 to 3 okay and he was 3.2 last monday and why did he take the warfarin today because of af af yeah like I didn't wanna be on a dunk or a big towel or an oxbow or anything like that he started on 1 of the I can't remember but the consultant at the hospital not long after atoxaban mhmm but the consultant at the hospital this was several years ago wrote to the gp said I don't want this patient to be on a doxycycline I want him to be on warfarin okay and I don't know why have a clot or anything no no he had I'll tell you what he had he had a he had he had his heart operation about 10 years ago what heart pressure did he have he had 2 bypasses and a valve repair yep mitral valve repair yeah yeah mitral valve repair yeah mhmm and then a few years ago we were starting getting some absences mhmm so we went doctors doctors felt his pulse and sent him for I think it was an echo he sent it for but was asking for that anyway and the result of that yeah yeah he went on the warfarin yeah got it and what they said was he'd got whether is medical surgery a sticky valve okay I see fine so the mitral valve represents yeah that makes sense a bit turbulence around the mitral yes and has he got atrial fibrillation as well or or no well it looks like he does on on on thursday it would make sense if he did would you like me to ring my daughter a bump do you mind that would be really helpful for me and then we could work out the doses and get everything sorted because I unfortunately it's just 1 of those weird quirks of the nhs that I if you live around here I can access if you live in devon and cornwall in somerset I can access your record but outside of there I can't can't you I can't can't I you and your name is brogan yeah hello kerry hi are you alright so are you free to put talk yes so I have a lovely doctor here called rob miller so he's trying to get his head round so I've got all those tablets here and you know what he has don't you and why a lot of them and he would like to have a chat with you if that's alright yeah okay yes of course absolutely hi kane I hear you're a pharmacist is that right I am yeah hi I'm rob I'm the medical registrar here at torbay hi rob nice meet you nice to you thanks for taking the call and something else out I've got I've got this dossette box but unfortunately I can't get on his gp record obviously because he's not local yes so I don't know if you know any of the doses of his medicines per chance you don't that's okay I'm sure I can work it out by calling his pharmacy or his gp or getting 1 of my pharmacists to do it yeah yeah well if she yeah yes so it's just of course because there's no labels on it is that she got home did you anne took a photo recently of the list of medication yes I've I've got that here kerry is that a list oh great no it's the same a photograph of this list oh a photograph of this list not the printout from the gp no no printout from the gp but it I can remember off the top of my head we reduced the when he was in when his egfr was reduced last time we reduced the dose of ramipril yeah and it was from 10 down to 5 then they did put it down to 2.5 I think oh I don't know if they did I don't think it went down to 2.52 0.5 no it's still on 5 I'm sensing that this is gonna be challenging for you if it's all off the top of your head right yeah if you had access to something if you had a list then that's then that's fine but if not we can get a list because we've got my medicine box in my house which they can go in and get well I'll I can sort this all out I can speak to the gp or the pharmacy they'll still be open and they'll be able to give me the list so don't worry if you had a list I thought you might be able to tell me but if you don't I can sort it out thank you yeah sure we do have access to the nhs n plan isn't it yeah yeah oh yeah that would have been ideal at this. To to just look at you're upset will it be on my own karen no I think you're probably on the same no do people have access to that sorry that's a conversation for another time that's fine what I'm really sorry that could be off the top of my head I want it off the top of your head because I'm gonna prescribe it so I'd probably get it sorted thank you very much yeah no okay then thanks for your time thanks yeah cheers I'll talk pleasure alright bye have a little sniffing think yeah of course good thank you no I'm not going yet I'll sort of have a minute no I I I'm just wondering if it's it's an yeah the warfarin makes you makes you bruise doesn't it what nice is it it's warfarin isn't it probably is warfarin yeah yeah it's okay thank you it's okay and then sorry he he was back so back to the story he got short of breath oh he left it's alright we've gotten distracted it's fine short of breath before you left he was coughing a bit and you think it's been a bit you've all left holiday you mean yeah left holiday and then last night he was coughing again all night yes but I did ops during the night yeah things were his blood pressure was improving a bit and you can see his temperature was gone slightly but not too bad yeah and then this afternoon he was very lethargic today you you just wanted to sit down didn't you so we were just sat in the lounge oh yes I was not sat very well no and he had some soup for his lunch then I took him to the toilet to do his catheterization and he sort of coughed you know how you clear your throat like that and loads of blood jangaloo so you didn't vomit the blood you coughed it yes and did that come out of your mouth we how to because he's had a couple of nosebleeds over the past few weeks and we thought originally but it wasn't it wasn't out of his nose it was out of his mouth when he coughed it okay have you ever had that before no no not the sacrum no because you remember coughing I don't know if you know the last time you had pneumonia I think you coughed up some blood then I can't remember pneumonia about the previous life okay my memory is not what it used to be no it's not I was staring down for my memory in the office yeah but it's not what it was yeah no it's calmed down bit myself and and then so he's had in terms of the back in terms of his past medical problems he's got type 2 diabetes he takes insulin which we've talked about he's had the mitral valve repair and he's had a coronary artery bypass graft the bypass anything else he's was in with diverticula diverticulitis yeah that what else have you got how long have you got what did you know how to smoke for for a while have you had lung problems related to smoking he smoked from the age of about 13 until he had his heart attack and when was that about 2008 he had his heart 8 operation in 2009 okay right yeah so that how long was that that would be what 40 years yeah yeah more smoked for 40 years did you more than that how long did you smoke for you were in your sixties when you had your heart attack started at school yes yeah and I was 14 15 like young kids yeah and how many a day did you smoke 20 a day up to 20 yeah yeah alcohol do you drink never more than 20 or 30 yeah that's okay and do you drink alcohol it's it's never been a big drink never been a big but since he's been on donopetsil mhmm for his memory he's had now okay he's stopped alcohol altogether oh nice yeah oh I just didn't get that alright thank you fine alright can have a quick look at you do you mind just lick at your hands and listen to your chest you're not stuck I'm awakened for the moment yeah and what did you do for a living you were in the office you said I did a solicitor practice you were a solicitor no not a solicitor a legal object okay fine great you weren't a legal advocate you were a legal accountant and you were a probate christian probate practitioner well the same sort of thing of equal merit how do you feel about sitting forward would you be able to sit forward so I can have a listen to your back gonna get magnified deep breath whatever you're ready no that's perfect and same thing okay that's the same thing I'll just take the medicine to your home again that's fine thank you sorry that tummy tuck for those like that think 2 or 3 pain in the tummy sorry any pain in the tummy I occasionally have pain in the tummy mhmm first oh excuse me last last few days yeah last few few days yeah insulin injections that's fine this is good this now 03:09 at 07:00 thank you very much and how are your legs have they puffed up at all no no I think they have don't you think do always have that much fluid on your legs he does have some fluid around his ankle sorry poor surprise and anything just to check for the I played small cricket and football until I was running from the forties great so you can imagine that it took a bit of a place then yeah I bet yeah fine and have the a and e team explained about the results of the tests they've done or anything like that to you do you guys get I'm trying to go at 7 8 7 I think I've got his tablets up here oh great that'd be pretty if not I'm sorry I could get through to a pharmacy or someone could count it 787 what did I say glenn 309 309 you have managed prescriptions oh you ever say good your approved prescriptions there we go you imagined that's brilliant thank you so much no more than that it's good to go that's of course I can access you know when you say today when we're going on holiday I forgot a copy of prescription I always say I've got it on my phone because I've got permission to see your records did you get that permission do I no I did give you the permission right I'll get you the information warfarin is currently on 3 day 3 1 mg tablets a day and 4 on sunday okay 2 to 3 you say is tiger that's and his last 1 was 3.2 and you said his dose again was 3 it's 3 30 per gram yeah 3 1 mg yeah a day but 4 on sunday at the moment I'll be back again next monday brilliant great let me check his thyroid again he's super old out thank you finasteride and then we can cough okay what's that probably the 2 like 7 for the $2 version yeah then he's on libra 2 but he just gives him a new 1 the sentra yeah yeah mhmm and he he has a separate branch that he'll be now I've got that with me fine I can get we will be able to get some a similar 1 or you may to leave it 1 so you know what it has yeah that's fine thank you and we well we well suggest we're probably long term capital ones in the us why do you think yeah he's it out before he goes yeah very fancy for him yeah so that'll be a lot easier for us to monitor yeah okay so the I've seen a couple of tests but the rest of his blood tests haven't come back the first test that has come back is showing the markers of infection when the blood are high his body's responding to infection his lights are up his chest x-ray shows his blood biological changes so it could be the 1 I earlier again again yeah and he wouldn't right in favor was he eating better good bit of oxygen really he's eating 7 7 l or so of oxygen which is a risky bit we need to get him to cough up some of this stuff because I think look he's able to expectorate it sounds like he's got lots of stuff in his chest if he can bring that up it should be pretty crackling in his that's what that is yeah that's the sound we're getting sounds good you've got a lot of stuff on your chest probably then you know that crackling yeah that you got on your chest that I say oh you throat's crackling I'll start you on a medicine to help you cough things up and some misting marks to help you bring it all up alright alright and we can ask our chest physiotherapist to help to come and tap your chest to help you expectorate this stuff okay get 1 of the phlegm up and what's the prognosis now need to speak my mask is being here of course what keeps you in hospital is this this oxygen not me I'm deflecting responsibility it's this oxygen you've really got I got no responsibility for that but you are not breathing well enough to be safe off oxygen so once this oxygen is gone you're gone yeah but you just we just need to get your infection treated with some strong antibiotics I think you'll be on intravenous antibiotics for at least a couple of days in hospital yeah and moving around as much as possible having some chest physiotherapy to get this stuff off your chest and weaning this oxygen down yeah I'm just thinking in terms of of course the holiday what in the hotel you've been yeah oh about 5 minutes no worries we're close to 5 minutes yeah no worries about 5 minutes so we're 300 miles away from place stop and you'll have a lovely view of the bay from the water really nice view the best view in torbay and the breakfast is gonna be better than the hotel thank you that's alright it's a pleasure you're very encouraging good and and it'll be fine you're not a liar are you it was part of my job to think through the alright you've seen right through me then yeah fine we'll we'll get all these things sorted for you in terms of trying to get your stuff off your chest and treat this infection and then we'll take it from there I guess it depends what we do in a couple of days' time we might decide maybe better off going home and bringing him back up to leicester they can cross that bridge if we if we want go home on the coach on sunday on sunday yes yes I think I think it's difficult I I think it would be quite ambitious to get you out of hospital by sunday to be honest right okay so I think with those chest x-ray changes and the amount of oxygen you're on I think you need to make a pretty rapid recovery to be getting out of hospital or something I I could I could stay the day I couldn't book a room for a or as we go once you're a bit more stable and a bit less oxygen and not needing all of this intensive kind of care that you're in at the moment then we can think about trying to transfer from here up to leicester hospital mhmm and we could try and sort all those logistics out but for now let's make you safer yeah yeah because you're you're a bit poorly for that now okay well thank you doctor miller okay I'll go very encouraging thank you for your help and thank you for your attention I'll see you guys next week alright thank you on examination heart sounds 1 and 2 with pansystolic murmur bilateral fine and respiratory crepitations to the mid zone on chest examination sternotomy scar abdomen soft and nontender pitting edema to the knees bilaterally on 7 l of oxygen medications list ramipril 5 mg once in the evening amlodipine 10 mg once in the evening atorvastatin 80 mg once at night busoprol 2.5 mg in the morning donepezil 10 mg in the evening tamsulosin 400 micrograms in the morning thiamine a hundred milligrams in the evening finasteride 5 mg in the morning furosemide 40 mg in the morning and at lunchtime lansoprazole 15 mg in the morning also taking insulin in basal bolus regimen and warfarin with target of 2.5 indication af and mitral valve repair lifelong 3 mg once a day and 4 mg on sundays impression evidence of bilateral changes on chest x-ray possible bilateral pneumonia versus viral pneumonitis with bacterial superinfection plan number 1 iv antibiotics number 2 blood tests including renal function using these and inflammatory markers number 3 continue oxygen therapy number 4 blue swab number 5 sputum mcns 6 hematinics number 7 enter the impression anemia of unclear cause no known drug allergies social history lives with wife diagnosis of dementia mild is independent around the house and independently made out outside the house