Jason proud 1134065 54 year old man present complaint shortness of breath and chest pain investigations lateral flow negative chest x-ray today long standing elevation of left hemidiaphragm left hilar contour enlarged possibly due to degree of rotation mainly consolidation of pleural effusion identified full stop repeat the chest x-ray advised to reevaluate the left hilar and retinol 135 from a baseline of 111 electrops normal lfts normal crp 15 previously 15 on the december 4 and 8 prior to that urea 5.4 ast normal inr 1 but high fibrinogen a negative quad swab full black count white cells 11.2 with neutrophils 8.85 under the respiratory team with copd mixed anxiety and depression in may he was admitted in february with similar symptoms of progressive breathlessness and some left sided pleuritic chest pain flaturation is normal at the time of respiratory follow-up he uses salbutamol inhaler up to 4 times a day and also uses trelegy inhaler fluctuating symptoms when reviewed in clinic in april lung function tests f e 1 1.94 64% of predicted fvc 3.3198% of predicted fev 1 fvc ratio 58% consistent with moderate obstructive lung defect peak flow 314 66% of projected and gas transfer dlco 70% are predicted kco 87% predicted his breathing tests have confirmed a diagnosis of copd and he switched from his trelegy to a trimbone exhaler 2 puffs twice per day he would benefit from pulmonary rehabilitation apparently a d dimer has been sent but it's not back yet on day the cardiac screen is back 8 locations list subismol inhaler 1 or 2 puffs 4 times a day as required fluoxetine 20 mg at night trilogy ellipta 92 / 55 / 22 micrograms inhaler 1 puff to be inhaled each day venlafaxine 75 mg at night mirtazapine 30 mg at night and trimba 87 x 5 x 9 micrograms 2 puffs twice a day examination of cpd at february 25 where he was admitted nondiabetic hyperglycemia cannabis dependence coded in 20 twin 20 10 I should say eupd in 2009 rathema coded in 2,004 tinnitus previous suicidal ideation coded as well as gout allergic to intolerant to statins but he's prescribed them several food allergies observations respiratory rate 28 sat's about 6% heart rate a 106 blood pressure a 123 over 88 temperature 36.9 in afebrile throughout his time in the emergency department observations have subsequently improved to 17 respiratory rates per minute and 94 beats per minute blood pressure 117 over 80 with temperature 36.8 saturation is 98% on air fine but also has antibiotics is it still mhmm fine is there anything here that we could we could titrate up his food ray whatever oh no okay where it work where it works for you it's nice to meet you how are you feeling in terms of your chest oh down a bit good otherwise I may be helped mhmm I just feel a bit shaky still but I'm alright yeah you know I don't need to be here but I don't need to be do you know what do you think well you're tracing your heart quite fast yeah there's nothing worrying on it there's no ischemic changes or anything concerning but you are going quite fast it raises the possibility of another cause for the shortness of breath yet haven't you yeah I guess we're worried about that I think you saw did you see doctor roland recently yeah last week day and what did he say he sent me for my x rays yeah and they were the same as so when was the difference april agreed and no change agreed he checked me with that thing all over he said I sound alright mhmm I had a doctor this morning with your gp yeah not my gp but my respirator your respiratory nurse or yeah carol who's after me nice and she knows I'm not well mhmm yeah so I saw a doctor you should just tell her if you're not happy and you want to make sure you're okay properly to go to the hospital yeah fine hi and here we are with the woman nagging as well anytime I help her who's the nagging woman your missus she lives in london okay and she's seen her wife no no no you know what I mean is this your wife no no fuck that okay fine fuck that so what's been happening then so you saw simon on thursday were you this bad on thursday no no but thursday night I didn't feel too clever because it takes it out of me in what way didn't you feel too clever belly I was breathing a bit erratic your tummy hurts yeah so I find it hard to get the energy to get rest mhmm let them get out of the door it doesn't happen mhmm you know so today is the first day since thursday I've got to rest because I had to go to doctors otherwise I'll be in my pajamas still because I know I'm not alive mhmm you know but just feel better so you didn't feel too clever on thursday night in what way didn't did you feel bad my stomach your stomach was hurting and your breathing was bad as well yeah I know because I had an appointment on today at a doctor's oh did you I try and hold off yeah fine I don't like to be a burden and did doctor rolland change any of your inhalers or anything like that no they put me on some medication oh yeah carbocetin I think it starts with a c I'm not a 100% that's fine yeah but I just my head is angry with me at the moment yeah of course I've just started them and I don't know if that's made me feel anxious or or way my heart is I'm glad I got 1 yeah of course and do you have a the the medicine that you were given or a prescription for it or anything like that well on me yeah I've got a salimol on me that's it k I am on trimbo yeah 3 puffs in the morning 3 at night mhmm but blue 1 as and when yeah do take a statin in the evening what do you take a a statin atorvastatin something different you don't take that for my cholesterol yeah yes it is not a statin because that makes me ill okay right so it's something else okay well no yeah fine I'm not very good at names that's okay that's alright in plain english I'm okay yeah yeah you know I am on something for my cholesterol yeah yeah and then this new medicine that you had started on you're not sure what it is fine and how many times a day do you take this new medicine twice morning and night morning and night 1 1 tablet well 6 weeks he's trying me 6 week trial I'll have a look I'll see if I can work it out I'm sorry I just don't it's not your fault don't worry a problem for the pharmacy here to read it alright fine doctor's a quite nicely yeah know stand and what day is it it's tuesday today isn't it yeah so you've been poorly now since thursday friday saturday sunday monday tuesday 5 days 5 days this isn't my. No I'm at all yeah you can hear I can you know yeah yeah and are you it worries me are you coughing coughing mhmm or dry cough a dry cough nothing comes nothing comes up and has that changed your cough don't really know I think so fine do you know any fevers or anything like that I got it for a while yeah fine but I get hot and I get cold mhmm do you know yeah I don't know yeah and in terms of the number 1 thing for you is is the heart the kind of heartburn feelings is that right similar is that is that what's brought you to hospital the the pain in your tummy yeah it feel like you know like when you get so lodged in your throat feels like out of there mhmm you know it just and do you get do you get heartburn not really I'm 1 of my I'm 1 of the lucky ones I can eat what I like and not put it on but I could have a fancy year ago doc good I'm glad that's because of you a lot sorry 40 odd years of smoking many how many were you smoking for that time 40 40 a day 50 wow but I gave up I gave up a weed 3 years ago brilliant like that right blunted happy really happy about that good for you and I've got this app on my phone about me smoking and I've done that a year and 2 weeks and 6 days today congratulations which is really good really good but don't ask me if I feel any better because I don't yeah fine but I feel 10 times worse oh sorry so I didn't have all these when I smoked mhmm but I probably did probably did but you didn't realize it yeah I don't know do you and who lives at home with you you're by yourself mhmm any pets or anything like that any birds no no birds no birds feathered or or otherwise I saw her today yeah alright she stabbed me once twice 3 times mhmm horrid aren't they take her out for dinner good idea and do you drink alcohol I can't no fine the I haven't had last bit of alcohol I have with chanties okay not big deal june yeah but I was up north okay I drove up north a week after being ill and I shouldn't have done it really okay but I went I went fishing with a few mates up there mhmm and then when I had a had a drink and food and you know yeah and of course I know what you do that's what you do you do it yourself exactly I do yeah but I had stopped the shanty because it couldn't do the hard stuff I had I've had a couple of times before local mhmm before I went away and it just makes me feel really warton 3 days and I struggle to get out of bed not worth it thank you yeah fair enough and how about work have you have you worked before work for a long that's fine long time with your chest it's gonna be difficult isn't it yeah well can't even get out of door at times yeah I bet you know yeah are you local yeah I live in darlington okay mass do you know do you know talkie yeah I know talkie right do you know shedding hill yeah of course I live right at top of hill oh my god you know the oap's home yeah yeah I live opposite there fine okay right bloody big hill though now you can now you understand what I'm gonna about to get yeah yeah but I can get down here can't get back over get back up here yeah that's so if I wanna go for a walk yeah go down and I've got 45 minute walk all the way around yeah and that's not funny no it's not funny no drive yeah I like my fishing okay I love fishing in the sea in the sea mackerel yeah dogfish rice okay you know I'm getting there you can eat the mackerel though so that's something no you're not keen hole team you got a cart around the neck and all the down it's tough as well isn't it you you better off finding someone who can actually do that yeah fishy mango you know I think you're better off getting fish and chips I'm I'm not off fish that well okay right you just love catching them not eating them not bait okay fine I'm with you fair enough yeah I like to I like to get out when I'm fit enough as much as I can because it's good for me yeah my missus says I ever do it my respiratory nurse she says ignore your missus you go and do it because it's good for your lungs good for your lungs yeah to be in the fresh air and I try and I try and park within reason so I don't have far to walk because that's a mission mhmm of course where I live if I go shopping for myself my car parks around 1 side of the building and I've got to come out of the car park walk halfway up the road to get into my building until it flows as dead that's tiring and that's normal for you and what is it worse now it's worse since in what ways last year but since thursday is it worse I haven't been out haven't been out today yeah you know so fair enough there's a lot going on at the moment yeah I bet you know my sleep is diabolical yesterday morning I went up about 6 I knocked it out since 24 hours yeah of course I'm on it quite early mhmm you know but I just struggle yeah of sleep at the moment alright so can I have another look at you if you might no hold my hands fixed up and just listen to your chest and stuff yeah this is what I'm sure I'm alright yeah of course nothing's dry mate I'm gonna take my trousers I guess start by looking at your hands if that's alright don't have to take anything off I'll just lick your hands good man you're a young doctor me are you fully qualified I mean I've just started it's my first day fuck off I know you're different I'm 32 oh yeah well I don't want to have a glide I'm 54 yeah you're looking alright for 54 I like you look good that's lovely though you got a full head of hair yes got good fish on the end of the line we'll go right past that mhmm big breaths for me and mhmm inside at this top if that's okay try again for me very nice your chest doesn't sound wheezy at all no I don't know if you were wheezy before you had the nebulizer did you feel like you were wheezy before a little bit a little bit can I have a look at your legs you're like any swelling in your legs or anything like that yep your chest is nice and clean I've always been skinny little once and have you explained your has anyone explained your blood tests or your swabs to you or anything like that don't know what I know my covid is clear clear okay and you've had some swab for flu and it's and and that's also clear no your blood tests show that your markers of inflammation are slightly raised which means what there's a possibility that your capd is exacerbated playing up playing up right exactly but to listen to your chest it doesn't sound that bad your heart's going quite fast there's the possibility of a clot on the lungs causing this so it's between copd playing up versus clot on the lungs and a blood test will help us work out which 1 is which so you've my blood test I've got it already have you got my results I've got most of the results everything looks fine apart from the raised markers of copd playing up infection and inflammation I'd like to add a blood test on you don't need another blood test but I'll ask the laboratory to test 1 more thing the thing there yeah there's stuff that's already gone off they've already got it in the lab so they'll just do another test on it to see whether you've got a clot on the lungs that's d dimer so I'll ask them to add that on and if that's positive then I'll give you an injection to thin your blood and plan a scan for you to make sure you haven't got a clot on the lungs tomorrow alright well what do you want to do I don't mind I can send you home it's fine but at the moment you're you're in a bad way with your chest aren't you you know we haven't really got to the bottom of what's going on just yet do you want to try some antacid medicine for your for the burning behind your breastbone omeprazole it's called okay it might be good it might make you feel better I'll ask the nurses to get you some of that maybe it was my copd playing up yeah I know the doctors this morning wouldn't they have put me back on steroids well I thought so too which is what makes me think that you might not be having playing up copd I would have thought the simple thing would be to put you on steroids like normal I haven't felt this bad for a while sorry you know so I don't really wanna stay in hospital if I don't have to of course so so I'm gonna be honest no no 1 they have to pay me to come here so oh no you have to go to the home yeah of course yeah of course I know I'm on my own mhmm my car's halfway to adaista so I've gotta go walk to the car anyway it's a long way isn't it believe it far is that do you know where the old post office used to be I'm parked there yeah fine so I walk through the ancient house park car park yeah fine I know what you mean yeah yeah along that long road yeah yeah yeah yeah he brings you out by a pub but exactly and then by little then you turn up yeah drop the hill it's not far on a good day no it's not a good day out there today though is it it's awful out there isn't it well no it was earlier I think we need to see what this blood test shows if there's a sign of a clot on your chest then we can talk again but my feeling would be to keep you in hospital but if there's no sign of a clot on your chest then I think we could get you out take an hour alright is that alright yeah cool let's get it sorted though do I have to have that skillet it's only plastic so you should be able to bend your arms yeah alright little awkward isn't it is it awkward little awkward it's in an awkward position really isn't it because it's your coach yeah so I put 1 there I put 1 there and I fled and fled and bled you like that and then I put 1 there and then my god you've got a lot of cones I know fully flat down I've a face drop down I've swooped my fishing in 1 of them of course I need to stay warm yeah yeah there you go I'll put you back in there I'll get on with the sorted for you I'll come see you with the results in a bit okay yeah I know I I won't be an hour but alright how are you doing today right so no impression exacerbation of copd likely noninfective versus pulmonary embolism clear chest although after nebulizers makes exacerbation of copd less likely along with lack of cough full stop <\n> Tachycardia on ecg makes pe a possibility especially in the context of chest discomfort possibility of gastroesophageal reflux disease plan try libomeprazole add on d dimer if d dimer positive for ctp and anticoagulation if d dimer negative then manage for exacerbation of copd given not requiring oxygen could go home with oral steroids and safety netting if stays in hospital for treatment dose low molecular weight heparin until scan to ascertain which medicine started by the respiratory team by review of the patients in a moment