Transcription - 20260108T 02-39.mp3

Written in retrospect of previous events on the ward this is paul veal 512244 subsequent to review updated the family 3 sons wife and daughter-in-law in the family room explained the findings of the ct scan demonstrating a 14 centimeter upper quadrant mass consistent with the possibility of a lymphoma with some areas of central necrosis and some some features abutting vasculature and other structures with the possibility of invasion explained that he had become more unwell this evening acutely agitated and confused and difficulty with breathing requiring large amounts of oxygen explained that my working diagnosis that he aspirated secondary to parkinsonian crisis secondary to missing his medication because of the compression of his stomach because of his lymphoma explained our next steps and plan as documented previously family were accepting of this and had some questions they're obviously medical and so and so I was able to answer these for them and they understand what's going on discussion with itu who are at trauma call at the moment and so unable to attend immediately sub approximately 20 minutes after review went to see the patient sats of 75% on 15 liters non rebreathe remains low gcs recheck gcs and gcs is 6 I was worried that he's peri arrest so I put out peri arrest call arrest team arrived and itu sha had long conversation with the itu consultant and I was also able to speak to the itu consultant feeling from the itu team after reviewing his investigations and their his imaging is that he's had a significant aspiration event sometime today possibly secondary to his parkinsonian crisis but also secondary to the distortion of his stomach from his lymphoma probably or possibly another intra abdominal malignancy the it consultant notes there's no other lymphadenopathy on his ct scan the it consultant feels that intubation and ventilation at this. Is not going to be beneficial as his you alright try and pass over this yeah discussion was that intubation and ventilation at this time won't be helpful as he's had a significant aspiration event and that there he worries that he wouldn't be able to get him off the ventilator and even if he did get him off the ventilator he would be profoundly disabled and unlikely to be a candidate for any treatment for this lymphoma he suggests informing the family of this which I've done he suggests citing in a ryles tube and transferring the patient to our respiratory ward to undertake either high flow nasal oxygen or bipap depending upon our preference he recommends airvo and not bipap but my concern with his high per his high c o 2 is that he won't respond well to and will continue to be more and also we need to give time for the rutigatinib patch to work for his parkinsonian crisis so the plan is to establish him onto bipap transfer him to midglee ward which is our respiratory ward then site a ryle's tube subsequent to that and a follow-up chest x-ray following the ryle's tube to ensure it's cited correctly I've updated the family of all of this they understand they have no questions and are aware how unwell he is at the moment

Medical ST5 Miller Clerking

Presenting Complaint:
Acute deterioration

History of Presenting Complaint:
This is a retrospective note following acute deterioration of an inpatient. The patient became acutely agitated and confused this evening with significant breathing difficulties requiring large amounts of oxygen. Working diagnosis is aspiration pneumonia secondary to Parkinsonian crisis, which occurred due to missing medication caused by gastric compression from his newly diagnosed lymphoma. Approximately 20 minutes after family review, patient's oxygen saturations dropped to 75% on 15 litres non-rebreather mask with GCS falling to 6, prompting a peri-arrest call.

Past Medical History:
• Parkinson's disease
• Upper abdominal lymphoma (newly diagnosed)

Drug History:
• Rotigotine patch (for Parkinsonian crisis - recently missing due to gastric compression)

Allergy History:
Unknown

Social History:
Family includes 3 sons, wife and daughter-in-law who are medically knowledgeable and involved in care decisions.

On Examination:
General Appearance: Acutely unwell, agitated, confused with breathing difficulties
Observations: O2 sats 75% on 15L non-rebreather, GCS 6
• Respiratory: Significant respiratory distress requiring high-flow oxygen
• Neurological: GCS 6, features consistent with Parkinsonian crisis

Investigations:
• CT scan: 14cm upper quadrant mass consistent with lymphoma with central necrosis, features abutting vasculature and other structures with possible invasion, gastric distortion, no other lymphadenopathy

Impression:
Aspiration pneumonia secondary to Parkinsonian crisis
Secondary to newly diagnosed upper abdominal lymphoma (14cm mass)
Acute respiratory failure

Management Plan:
1. ITU review completed - intubation and ventilation deemed not beneficial due to significant aspiration event and poor prognosis
2. Transfer to Midgley Ward (respiratory ward)
3. Establish BiPAP ventilation (preferred over Airvo due to high CO2)
4. Site Ryles tube following transfer
5. Follow-up chest X-ray post-Ryles tube insertion to confirm correct placement
6. Continue rotigotine patch for Parkinsonian crisis
7. Family updated and understand current situation and poor prognosis
8. Escalation plan: Not suitable for intubation/ventilation as per ITU consultant review - would be unlikely to wean and would result in profound disability precluding lymphoma treatment

Summary

Investigations

Plans

Medical ST5 Miller Review

Reason:
Acute deterioration with agitation, confusion and breathing difficulties in patient with newly diagnosed abdominal mass

History:
Patient became acutely agitated and confused this evening with difficulty breathing requiring large amounts of oxygen. Working diagnosis of aspiration secondary to Parkinsonian crisis, likely precipitated by missing medication due to gastric compression from lymphoma.

Examination:
Sats 75% on 15 litres non-rebreather mask, GCS 6, peri-arrest state

Impression:
14cm upper quadrant mass consistent with lymphoma with central necrosis and possible vascular invasion. Significant aspiration event, possibly secondary to Parkinsonian crisis and gastric distortion from intra-abdominal malignancy. ITU consultant assessment: intubation and ventilation not beneficial due to poor prognosis and unlikely ventilator weaning.

Plan:
1. Establish BiPAP ventilation
2. Transfer to Midglee ward (respiratory ward)
3. Site Ryles tube
4. Follow-up chest X-ray post Ryles tube insertion
5. Allow time for rotigotine patch to work for Parkinsonian crisis
6. Family updated and understand current situation

Summary

Investigations

Plans

EMERGENCY WARD CONSULTATION - ACUTE DETERIORATION

Written in retrospect

FAMILY DISCUSSION:
Updated family (3 sons, wife and daughter-in-law) in the family room. Explained findings of CT scan demonstrating a 14cm upper quadrant mass consistent with possible lymphoma with areas of central necrosis and features abutting vasculature and other structures with possibility of invasion.

Explained patient had become more unwell this evening - acutely agitated and confused with difficulty breathing requiring large amounts of oxygen. Working diagnosis: aspiration secondary to Parkinsonian crisis secondary to missing medication due to gastric compression from lymphoma.

Family were accepting and understanding of the situation. As they have medical background, I was able to answer their questions appropriately.

ACUTE DETERIORATION:
Approximately 20 minutes after family review, patient review showed:
- Oxygen saturations 75% on 15L non-rebreathable mask
- GCS 6
- Peri-arrest state identified

Peri-arrest call activated. Arrest team and ITU attended.

ITU CONSULTANT REVIEW:
Long discussion with ITU consultant regarding patient's condition. ITU assessment:
- Significant aspiration event today, likely secondary to Parkinsonian crisis and gastric distortion from lymphoma (or other intra-abdominal malignancy)
- No other lymphadenopathy noted on CT scan
- Intubation and ventilation deemed non-beneficial due to severity of aspiration
- Concerns patient would be unable to wean from ventilator
- If successful weaning occurred, patient would likely be profoundly disabled and not candidate for lymphoma treatment

PLAN:
1. Insert Ryles tube
2. Transfer to respiratory ward (Midglee Ward)
3. Commence BiPAP (ITU recommended Airvo, but BiPAP preferred due to high CO2 concerns)
4. Allow time for rotigotine patch to work for Parkinsonian crisis
5. Follow-up chest X-ray post Ryles tube insertion to confirm correct placement

Family updated on all developments. They understand the situation, have no further questions, and are aware of how unwell the patient currently is.

Summary

Investigations

Plans