Clifford moors 6 88 950 so clifford moors 6 8 89 5 0 68 year old gentleman medications list dapagliflozin 10 mg once a day atorvastatin 40 mg once a day glypizide 80 mg once a day metformin 1 g twice a day aspirin 75 once a citalopram 40 mg once a day 5 mg as required lanzoxazol 30 mg once a day dipyridamole modified release 200 mg tablets twice a day regurin 20 mg tablets twice per day regurin is trospium chloride for overactive bladder past medical history hypertension anxiety stroke possibly 2005 permanent pacemaker 2017 2 diabetes mellitus 2019 with microalbuminuria note on reviewing gp record note multiple falls over january and december as well as november he's recently been investigated for weight loss through the gp team regarding multiple myeloma and underwent a ct thorax in november which demonstrated a left apical spiculated opacity with adjacent progressive pleural thickening he was subsequently seen in respiratory clinic with doctor diggins in the december 17 which in light of this increasing spiculated opacity in the apex of his left lung he's had 6 to 7 stone and weight loss over 15 months which was unintentional with a good appetite in terms of his occupational exposure he worked as a motor mechanic was exposed to asbestos and brake pads but no known exposure to tb in terms of his functional states he lives alone he uses stick outdoors with an exercise capacity of 5 minutes on the flat he has support workers to help with shopping which he has had since his stroke for about 15 years and has some assistance with showering during the course of a week he has friends nearby and has never had any kids terms of past medical history additionally he's got a phenotypic mitochondrial cytopathy with restrictive pulmonary function tests and impaired swallow as a result of that nafld cirrhosis with portal hypertensive gastropathy sleep disordered breathing on cpap previous asbestosis and pleural thickening type 2 diabetes pacemaker stroke in 2005 and hypertension it's a ddd permanent pacemaker saw doctor neil in clinic in 2021 with treated for pancreatic exocrine insufficiency in terms of his liver care he is managed by doctor summers an ultrasound suggested splenomegaly in the context of possible mast cells underwent an ogd in november 2024 demonstrating mild pulsatile hypertensive gastropathy incidental 2 cm segment of uncomplicated barrett's so in terms of the investigations venous blood gas initially ph 7.29 with base excess of - 10 improving now to ph 7.41 with base excess 2.2 potassium 3.4 when previously was 3.1 lactate 3.4 when was previously 2.9 p c o 2 5.8 in the venous system inr 1.4 previously 1.2 in december ct thorax abdomen and pelvis trauma full series left frontal soft tissue swelling left sided rib fractures multiple new right upper middle and lower lobe pulmonary opacities with surrounding ground glass attenuation concerning for infection enlarged right parasophageal node significant enlargement of previously seen left apical spiculated mass with now showing cavitation kinks in the anterior left eighth and ninth ribs likely nondisplaced fractures further nondisplaced fracture of the anterolateral tenth and eleventh ribs multiple new right sided pulmonary opacities are surrounding glangus attenuation and tree and bud nodules concerning for infection passively collapsed urinary bladder surrounding fat surrounding clinical evidence of urinary tract infection? Of note liver appearing normal on ct alright hello are you on your own you're done on medics of note there's pancreatic atrophy and calcifications as noted previously fecal loading in the rectum there's no cns injury skull fracture on the ct b 12 and folate's normal ferritins 1,407 tsh is normal full blood count hemoglobin a 151 neutrophils 20.37 and white cell count 24.3 al the albumin 29 and alp a 137 calcium normal eosinase normal with creatinine 101 from baseline of 69 so it's not normal it's an aki stage 1 but normal electrolytes liver function tests normal ck 1020 crp a 148 when previously was 2 urea 12.9 when previously was 4.6 ast normal magnesium of note I can't see that he's been tested for tuberculosis as a potential underlying cause of this cavitating lesion but he has had aspergillus serology which is negative alright so letters so observations heart rate 126 saturation is 96% on air respiratory 20 blood pressure 89 over 61 ecg sinus tachycardia narrow complexes rate a 117 actually I think it's more likely to be af with a fast ventricular response needs repeat ecg reviewing his glucoses glucose on admission was 23.8 and now 8 hi mister morse I'm ross I'm 1 of the medical registrars to meet you I'm fine how are you I'm feeling a lot better you're flat that's good in what way are you feeling better in yourself in yourself yes good I'm glad and tell me all about it what happened I don't know do you what's the last thing you remember the police turned up I see mhmm and who do you live with at home myself with yourself fine and you live in a flat I understand yes and how do you get around the flat around you just walk around yes and how about outside I do struggle sorry to hear that in what way do you struggle I'm hurting that with part with your foot no I actually shattered the ankle but your ankle's fine yeah yeah okay and do you use a stick or a frame stick a stick very good alright when you're outside the house and how often is that when you get outside the house not often how often is not often it about once or twice a night okay do you go out to your own shopping okay yeah yeah to park yeah the the ketones the ketones wasn't working to be out of hospital so I've got the okay the end was normal so you get out of house a couple of times a week you do your own shopping and how about around the house do you get any help with anything I understand you have some support workers that come in yeah mhmm what do they help you with shopping mhmm do they go out shopping with you yes mhmm how about things around the house in terms of washing and dressing I don't she do that myself you do that yourself very good fine alright and then it's all a bit unclear what happened have you been feeling okay recently no pretty at times and I can see you've had a few falls over the last few months last few days last few days as well yeah how many falls have you had over the last few days maybe not 6 or 7 6 or 7 falls over the last few days yeah cool thing and what do you think the cause of that is I'm not sure not sure fair enough so then it sounds like the paramedics that came to see you said you've been on the floor for 36 hours because you have cleaners that come around your house is that right yeah and how often do the cleaners come I want to push are these the same people the support workers that help you with your shopping but they also clean your house for you no no they're different people no so the support workers come twice a week the cleaners come twice a week no fine understood possible I'd like to sit in a chair you're a bit too poorly to go in a chair at the moment I'm afraid I'm sorry your blood pressure's quite low you might pass out if you sat up in a chair so when they saw you they said that you your house was a little bit unkempt yeah and that and that you were found on the floor next to your bed on your back oh but very but quite sleepy at that time gcs 13 just a bottle another bottle I've always got a drink you can get you a glass of water that's fine this is fine a bottle a bottle I've only got cups and water I'm afraid fine is that alright uh-huh buffled alright can I examine you quickly is that okay uh-huh I understand you had a stroke before in 2005 uh-huh and what kind of what has that disabled you in any way no no alright good so why do you have the support workers and carers come to help you it's not it's a pill because of this metabolic this mitochondrial condition that you have yeah and how does the mitochondrial condition that you have affect you it affects the heart in what ways it's just for my face and all that mhmm okay that's fine so we've got cool peripheries you've got fast irregular pulses at a 130 dry mucus membranes I know I've been from the say again I've been back back up to 19 5 0 what makes you say that I think we've got to put it out sorry you feel like that why is that I don't know mhmm feeling quite low lately yeah feeling lonely yeah I'm sorry to hear that difficult isn't it I don't think the world would be better off without you and we're very happy to look after you here I'm sorry that your mood's been a bit low I can ask someone to come to talk to you about it if you'd like quick listen to your heart alright that sounds nice and normal I prefer you to repeat take some big breaths for me 73 please say again 73 thanks very much bilateral course palpitations just touching your legs hope that's alright sorry independent edema to the knees hurt your foot here taking a bit of the skin off we can dress that for you I'm sure have a look at your hands who are the bears red car a car red car bears red car bears a a football team yeah fine speedway speedway okay yeah fine do you smoke or drink no neither of the 2 clean living kind of guy I used to smoke used to smoke tell me about that uh-oh I pack up about 4 3 or 2 years ago good for you how long did you smoke for about 10 years about 10 years okay pain in the tummy at all a bit bit sore ah okay sorry sore on that left hand side yeah when was the last time you looked for a poo yeah yeah before all of this yeah yeah that bit of days ago probably sorry darling pop your thumbs nice and straight with your hands will that's fine so you the a and e team have already started you on some excellent treatment which has already improved all of your blood tests which is good you've been starved and laying on the floor for a few days so I suspect you have a starvation ketosis causing acid in the blood and acidosis because of that you have chest infections on both sides probably from breathing things in when you were quite sleepy on the floor and you were probably sleepy on the floor because you fell and hit your head given what we see on your face which is lots of bruising on the left hand side of your face and a big lump on the top of your head when being on the floor you've given yourself some pressure injuries to your bum and your back and so we need to keep a close eye on those to make sure they don't become infected or break down or anything like that as your body breaks down your muscle because if you're lying on the floor it can affect your kidneys and your kidneys have taken a bit of a hit so you've got an acute kidney injury because of that so you need lots of fluid to help wash that through so we'll carry on lots of fluid get you feeling better get your blood pressure better and then get things sorted out in order to keep a close eye on you in hospital I suggest we pop a catheter in to monitor your urine output is that alright thank you urology have tried we've oh yeah he's got very tight phimosis yeah yes I hear so if you would like clearly urine's coming out yes they did say that it's difficult to monitor everyone's checking what you're doing there yeah thank you I can give you a moxifloxacin I can do it for you no it's like cool well well then we're struggling to get a catheter in because of whatever reason but you are weaning so that's okay oh okay and I think the surgeons have tried and haven't been able to that sounds fine I'll just take this phone call and get we'll get everything sorted for you alright it was really nice to meet you thanks for talking to me about everything alright we'll get you sorted out so the plan is continue fixed rate insulin infusion until acidosis resolved unable to step onto variable rate continue iv fluids repeat ecg query af suspend ramipril trospium diazepam metformin if no if developed overload or not able to improve with iv fluid alone for itu review to consider vasopressor support if required to overcome? Of critical illness secondary to rhabdomyolysis secondary to long lie number next stay in recess