So next patient brian elwell 551762 86 year old man medications list ibuprofen 10% gel apply 3 to 4 times a day sodium valproate 200 mg per 5 mil oral solution 7.5 mg in the milliliters in the morning and 5 ml in the afternoon docusate oral solution 2 5 ml spoonfuls twice per day bisacodyl 5 mg suppositories 1 each morning for constipation lactulose 15 ml twice daily as required cholecalciferol 400 units per mil oral drops 2 drops per day amitriptyline 25 mg in 5 mil oral solution 5 mg at 03:00 paracetamol 1 g 3 times a day as required 4 times a day as required for pain thick and easy powder for thickened fluids circadin 2 mg modified release tablets take 1 at night clopidogrel 75 mg 1 tablet to be taken once a day latanoprost 50 microgram primal eye drops 1 drop to both eyes once daily gtn spray as required past medical history he lives in a nursing home he has had a first seizure july 2024 fall in april 2024 leading to rib fractures and pneumonia vascular dementia because of with mri in 2023 demonstrating multiple infarcts with associated difficulty in swallowing for which he has thickened fluids for open angle glaucoma b 12 deficiency previous fragility fractures bph 2019 first degree atrioventricular block 2017 ischemic heart disease 2002 angina 2000 hypertension 2000 investigations chest x-ray at 05:29 no significant change in appearance reported likely pleural plaque in the left mid zone follow-up x-ray advised when appropriate troponin t 1225 nanograms per liter liver function test alp a 136 but otherwise normal ast normal burst troponin t hemolyzed full blood count white cells 13.7 with 6.59 lymphocytes 5.41 and monocytes 1.58 otherwise normal euze and ease creatinine 49 patient's baseline sodium normal crp 50 urea normal venous blood gas lactate 2.5 ph 7.31 potassium 4.5 so the background is he's in a care home his wife visits every day he's hoisted but able to converse normally when well most recently admitted in december he's admitted for pneumonia with iv antibiotics ecg in recess demonstrating acute anterolateral st elevation myocardial infarction initial blood pressure 234 of it unclear sats 97% on 15 liters and broad complex tachycardia noted has been discussed with the cath lab by the ed team not for pci for medical acs treatment and ward based care the family are aware that he has a very poor prognosis following this already been started on antibiotics ivetazosin by the ed team plan is for medical acs treatment an isocare infusion for pain furosemide is required for pulmonary edema chest x-ray reviewed poor quality film but there is some hazy increased interstitial markings by basally with some upper lobe diversion of blood consistent with pulmonary edema so the plan is continue ivitazosin to cover for infection of unclear source msu sputum mcnf if this produces aspirin reload on clopidogrel medical acs treatment iced kit infusion for pain fruzema for pulmonary edema low threshold to palliate if it deteriorates further hi I'm rob I'm on my questions I saw you briefly in in yeah the recess area it looks like quite a bit nice yeah it's obviously a good thing because we don't need to do intensive things to him in there yeah yeah okay I've had everything that's happened before my colleague from the day has it who I think you saw briefly yeah but with his breathing and had some treatment for that yeah and I'm gonna have doctor just take me in and just come to say just meet him examine him and make sure that there's any symptoms that I can alleviate in the meantime make sure he's got all of the treatment for his heart attack while he's in hospital does he just wait for breathing for the weight no not really I mean it's been that breathing number's getting worse and the respiratory rate's hitting yeah heart rate's a 109 saturated on the third should treat 37 not sure a 100 but it started started to finally so it was like getting around 32 33 okay and then it has gone up to 40 yeah he's not any pain from his knee he's very warm mhmm but he's just had some different antibiotics and then the nurse thought that the fluids might help as well okay but he is warm he is definitely warm he feels like he's having a fever doesn't it yeah like behind him behind behind his back it's like very contract yeah and certainly the markers of infection and inflammation are slightly raised in his blood yeah so there's the potential for whether he's got chest infection along with this something like that I mean has definitely brought dad in here do you know what I mean didn't come in because he told us and he came in because of his breathing and his chest but obviously a problem with the heart can lead to fluid backing up in the lungs and that can cause problems with breathing and it really responded quite well for some treatment it works well to get fluid off the lungs it could really have been the heart all along as opposed to being a chest infection exactly right okay yeah it's difficult to see the heart rate has always been elevated whenever they've checked his stats so even if his temperature's fine and all of that stuff but the heart has still been high yeah of course can I have a quick listen to your chest I reckon doctor yeah let's take a look at how he's got a chest tube basically just run that off to sorry probably a little sore from the chest when I'm coming to the room try you down through the top of the ankle and I'm suggesting I'm just touching on the lower side his chest x-ray didn't really show too much no but when he was in there the other week was very inconclusive then and yet he had this huge rattle that he's just not been able to clear yeah certainly he was in around christmas time his markers of infection were more raised he was not consistent with an infection at that time more than this time much more than this time oh okay interesting but obviously having an infection but stress on everything because now he's been fighting a recent infection and then that's led to some damage to his heart working a bit harder and then having his heart attack yeah that's a possibility and you understand about the word worry about him and his heart yeah that he's had lots of damage to his heart with this heart attack yeah it's quite a significant heart attack yeah yeah I understand I understand yeah I understand good we give him lots of treatment medical treatment to try and help him unblock the arteries around his heart yes but it's very difficult to say you know how much have function that he left with and in this in this time when he's sleeping with and he's at he's very significant risk of worsening respiratory function and things like that I just figured that that that 30 seven's already touched 41 and not it's not that high it's just going to keep getting higher and higher isn't it it could do he's just going to get very tired and then he's just going to I understand catherine the doctor yeah well I think we've got lots of things we can do if that were to happen if he would have problems with his breathing we can rush and see him and give him more medicines to try and get water off his chest that might improve his breathing temporarily but it's possible that we'll go back to that same situation again the other option is to not do that and to accept that he he may die from that mhmm but to make give him lots of medicines to make him comfortable just go like that and we've got lots of things we can use to keep people comfortable in these situations are you alright alright dad are you okay any pain at all as well anything hurt negative not acute pulmonary edema possibility of concomitant to right lower zone community acquired pneumonia plan iv antibiotics iv furosemide as tolerated by blood pressure dual antiplatelet therapy already received 300 mg of aspirin as well as or needs re but needs reloading on clopidogrel continue follow the paradex 2.5 mg subcutaneously once per day stop iv fluids it's clinically overloaded tep not for resuscitation low threshold for palliation if deteriorate