Mister stephen welch 690687 78 year old man presenting complaint confusion well I don't know anymore or otherwise get investigations full blood count normal calcium and remainder of bone profile normal using his normal liver function test normal crp 20 urea normal ast normal phosphate normal magnesium normal venous blood gas normal chest x-ray normal heart side and mediastinal outline lungs clear ct head no visible acute intracranial abnormality background small vessel disease h b a 1 c 61 from 87 past medical history type 2 diabetes mellitus nonalcoholic fatty liver disease and metabolic associated steatosis liver disease medications list metformin 500 mg once a day novomix 30 flexpen subcutaneous injections we're allergic to tennis vaccine and wasp stings reviewing the gp record so collateral history from a gp record attended gp practice with planned diabetes appointment from on the january 29 for diabetes review at that time found to be a smoker of 3 cigarettes a day but not drinking alcohol at that. They found that he didn't know his phone number appeared a little confused walking into the room with his belt wrapped around his legs and walking at the same time stating he had stopped his incident himself he did not have his shoes on properly does not wear them and so not fitting properly and just sliding feet in and all buckled under his heel tried to encourage to put on to show show to put on properly to prevent any breakdown or sores but he refused he's if he needs any contact he's asking if he can have a letter sent about a week before planned to review with the diabetic nurse the next day he had some blood tests and then saw the diabetic specialist nurse earlier today where he said he hadn't taken his insulin since november blood sugars are 8 in the morning hp on c 61 better than previously no other diabetes meds prescribed atorvastatin in 2022 but did not take his memory denies his memory is poor normal mood does not know mobile phone number initially thought it was 2006 he did not attend his retinal screening no evidence of injection sites on his abdomen then subsequently saw the general practitioner doctor burrill concerns around lucidity and mood not been taking insulin bm 10.2 urine dip no ketones good job hi notes he hasn't been taking insulin for a couple of months not sure why I just decided to stop totally irrational says he's eating regularly especially vegetables and potatoes lives alone cooked for himself doesn't use a microwave often uses a gas hob notes he has set off the fire alarm a couple of times has noticed a recent cough triggered by what he feels are crumbs irritating the back of the throat nonsmoker rarely drinks alcohol lives alone assess with the 6 item cognitive impairment test which identified a score of 14 over 28 on examination he was unkempt with poor body odor and seemed acutely confused urine dip didn't identify any infection so I've got of work to do how are you I'm well I'm walking well good you're walking well aren't you good well that's good come on in just kinda sleep wherever you like any chairs the bed long would you prefer you're doing good chair very good lovely what anyway you got there it's a central foundation got to be what else is there anything nothing good in it you're probably right nothing like your observer no I know what you mean yeah I'm rob I'm 1 of the medical registrars pleasure to meet you in the club how are you well I'm fine and I saw the doctor and he said for a year I had 6 and a half ago sorry I know it's miserable isn't it you know all evening yeah well I didn't expect go and see the doctor and land up in hospital no I'm sorry ours doctors are terrible when we get our claws in you don't let go yeah you're right you are we are evil you went to see your gp because for your diabetic review is that right no they sent me a letter yeah tell me all about it what's going on I responded well I was feeling a bit rough and I wasn't taking the insulin must admit that didn't help anyway the insulin I took 20 things of insulin it still didn't kind of correct it sorry is that right yeah sorry I'll just make sure that you're here I'll just you're going with me after this to 28 I'll just hand over to the lucy the staff thank you sorry go on I lost my train you went to the gp and your diabetic news work because they sent you a letter and you responded yeah I responded yeah and I'll add that and then what happened well they just sent me for a memory test and memory's not so good well up to 78 years not too bad yeah fair enough yeah tell me about your life more generally how have you been feeling over the last few weeks few months or how boring you well I'm I'm okay with being better I mean people expect more of you but I can't give obviously in what way do they expect more of you what do you mean I don't know what they expect what doctors expect you know like I try to keep active as the narrative is to keep you know to keep active because I don't want to land up like well hospitals are great incentive like look at people and you think good god I could have landed up like that yeah we're lucky by the grace of god if you're a believer I'm not I'm lucky yeah we are very lucky you know I've still got 2 good legs you're good on them that's good isn't it and you live by yourself yeah in a flat in a house in a room in a room yeah in a shared house yeah in a shared house mhmm so there's a shared kitchen so there are other people there in the house yeah yeah it's pretty good they they wash up and clean up that's good you know it was 1 of the best kitchens out there sorry sorry they got a kind of lifting oh that's good yeah and whereabouts is it to moran road mhmm in torquay yep lovely and you what kind of people do you live with well probably human beings that's nice and you get on yeah good and how's your mood been lately how have you been feeling yourself in terms of your mood oh my mood my mood is pretty good good I don't get upset when people don't do things yeah so no I don't do things yeah of course yeah every human being expects every other human being to be perfect mhmm in which is impossible yeah and your gp was worried about your memory and did a memory a memory test there can be lots of reasons why your memory might be poor some of them come on suddenly some of them come on very slowly mhmm some of them are because you're feeling poorly for whatever other reason do you feel poorly in any way do you feel unwell in any way not really any pain passing water I just try to not eat too much like it's impossible to look down the street these days without finding someone trying to I just went in for a cup of tea and they oh you can have 2 cream cakes for a blah blah blah you know there's pushing pushing pushing pushing cream cakes are nice though aren't they yes I know but you've got to moderate moderate so you've been feeling well in yourself lately any pain passing water nope cough or cold nope pain in the tummy anything like that no take 1000 tablets a day do you 1000 mg of vitamin c okay and selenium lovely I take selenium fine that's nice which you can only get in tottenham's properly I live in darlington so I know it well oh yeah right yeah yeah yeah yeah yeah yeah yeah I love it in there yeah it's great mhmm I'll get my selenium fine from there from there that's the place with all the little bags of herbs and the yeah and the turny thing outside I like looking through those that's why I come to to turkey actually I come down to visit and I stayed well don't blame you I just well I stayed about 20 years ago where did you visit from I visited from the other way good it wasn't much back in the other way mhmm sorry to disturb doctor mila yes until what time are you 11 oh because there's no plan yet written for him he's in '28 yes so I just told the nurse there that you're still having a discussion I'm happy to write the plan of course will course write some notes yeah don't worry yeah yeah I thought she was saying in tottenham way back got a job got a flat we think it was much easier in those days like that must have been a great time 20 years ago in tottenham I bet yeah and tell me about you and how you look after yourself you cooking for yourself you cook for yourself I cook occasionally every other day every day I cook cabbage greens sprouts basil sprouts potatoes all in 1 nice and warm together nice kind of like bubble and squeak but without the spam sounds nice some butter in there mixing with it that'll keep you healthy bit of of biscuit and gravy on top very nice fine and obviously you cook with those other people that you live with at home not really don't because they don't eat greens how long do they not they're not on greens they weren't born up with greens all right what do they eat then I don't know they don't eat good food you know like for your system really they're eating crap yeah well the food has got a bit easy to buy what do you mean what crap food yeah yeah you're right isn't it it's hard to get away from it yeah there's only 2 bits in the supermarket actually have any food in isn't there those 2 aisles at the start and the rest of it is just crap isn't it unfortunately but yeah and any rashes on your legs or anything like that no pain in the small joints of the hands headaches visual changes I don't get headaches fine I don't suffer with headaches of course good because I take 1000 mg of vitamin c a day and I take a selenium I take 2 tabs a day 204 hundred a day they only discovered selenium 50 years ago really what they didn't know existed wow good tabs of selenium they're still discovering you know stuff any rashes at all none on your legs on your body no issues kind of like before anxious a friend of mine someone else who shares a flat he gets rashes all over he gets anxious and he gets these rashes get rashes fine that's good can I ask you a few questions to test your memory is that okay can you tell me how old you are 78 fine and what's the time roughly the time now it's just gone 12 yeah it's close to yeah it's 11:00 what's the year at the moment what what's what year is it 2006 okay it's 2026 2026 that may be when you moved to tottenham's 02/2006 20 years ago maybe you've been here longer than that I've been here what's your address 85 warren road very good and what job do I do what job do you do well you're a doctor oh yeah I don't know what you and that person that came in the room just then what job did they do I didn't really take much notice that's fine what's your date of birth what's your date of birth what did they did kind of get through I don't know I didn't really he was too tired he was too tired for my winter I'm sorry I know it's difficult what year did world war 1 start 1939 mhmm very good and who's the current prime minister of the country prime minister keema not a very good 1 yeah so understand that keema's a naan bread isn't it with with quinoa is a naan bread with beef in it isn't it I was say but he he doesn't he won't he's not like churchill stand up to to fusion no he doesn't wanna stand up you're right try his name again you're nearly there kiyostama very good and could you count backwards from me from 20 to 1 19 181716 keep going 1615 mhmm 141313121110987654321 amazing thank you and I'll give you an address to remember sure it's called 42 west street 42 west street right okay and and then tell me a bit about you so you smoke cigarettes don't you 3 cigarettes a day is that right yeah about 3 yeah yeah and alcohol not like I can't afford it yeah expensive bloody hell 4 quite a bit yeah so you don't drink at all or you drink a bit well I drink probably on a friday I think the barrel dark beer the barrel house yeah barrel house and lovely there and getting a dark beer mhmm like a porter yeah lovely once a week that's it what once a week that's it what's the word you said once a week yeah once a week about friday or saturday I have a couple of pints and any other substances any drugs no not that I used to used to but not at the moment but it's expensive yeah it's expensive everything's expensive I look at the I look at the money side of yeah of course things first what did you do for a living I was a test man k and was that on the isle of wight no that was in bristol in bristol fine then you moved to the isle of wight to retire no no I went to the I went to the I forgot what you said to remember that's okay I'm trying to distract you deliberately don't worry fine I'll ask you later don't worry it's fine okay I just forgotten that's alright do you mind if I have a look at your hands no go ahead thanks very much so much for those can't you you can see you've done a lot of work with them oh right so they're regular pulses I used to like cycling a lot running I've done a lot of cycling lately have you still got a bike yeah you smell a bit like bike oil oh really yeah you got a little bit of dupuytren's contracturing did your finger ever get stuck no good that's we have been coughing say again the doctor at the croft had a stethoscope on my back that said cough good cough I've x rayed you you haven't got any chest infection you'd be happy to hear alright is that is that good very good yeah can I touch your tongue somehow no excellent no don't suffer with cough how are your bowels when did you last open your bowels just recently actually here good about a couple of hours ago excellent I usually usually put in some rubbish for once a day yeah of course that's good isn't it and it goes through once a day get some roughage well I was brought up on 2 13 meat and greens that's what happened in the fifties totally different era yeah of course so now mhmm I mean you you give kids what what I ate then what do you mean you know like greens and yeah I mean I'm vegetarian so I eat a lot of greens but I can't imagine the average person does the vast majority of people probably don't eat any at all right when I speak I'm a gastroenterologist I'm very interested in the bowels I I I I turned to being a pescatarian when I was about 18 19 great I kind of fell in with people mhmm I think I'm as the same yeah who like to once you're off that awful stuff then it's great isn't it yeah well it clogs your vessels clogs your veins up not good for you is it and not poor not not even to mention all those poor animals yeah right so you've come to hospital you've had some blood tests you've had a big panel of blood tests to look for causes of confusion they're all normal 1 test is slightly raised a marker of inflammation or infection is ever so slightly raised but not really not bad for 78 not bad for 78 indeed you've had an x-ray of your chest which is plum normal you've had a scan of your head which is also normal it's almost certainly normal some tiny age related changes in your brain but anyone at 78 will have those changes yeah so there's nothing to worry about there if your memory is a concern to you then I could ask you to be seen in our memory clinic where we talk a bit more about things with mem talk more about bit more about memory different scans more tests to look for an underlying cause of confusion and things like that what do you think about that I if you feel confused about forgetting things you you don't feel confused but you do forget things I've forgot I've a hitchhiker across europe and I left socks shoes mhmm behind you know like when I was 20 yeah I was worse when I was 20 yeah yeah I bet yeah you seem alright to me you know I used to hitchhike across europe a lot when I was you know younger and forget things leave people with things in cars yeah of course I do that all the time everyone does that I think mean touring people who hurt perfect is aggravating you know can really get you all those rashes I suppose maybe you know like anxiousness being too anxious all the time not good for you is it good to be relaxed well I've never been really anxious that's good I was a hippie you still are I think don't you think well in a sense yes yeah yeah that's good yeah I still kind of then what do you want to do your gp's asked me to bring you into hospital but I don't think we're going to add anything by admitting you to hospital overnight oh no we've had an opportunity to do a really good mot and do lots of good tests to rule out any concerning underlying cause for what your gp was worried about your markers of infection is slightly raised and I think it could be reasonable to have a short course of antibiotics to cover for an infection but I don't know what I'd give you them for we've got to use antibiotics we love them yeah I know you love them but they kill everything agreed and you've got to eat some stuff to kinda regenerate it does wipe out your gut flora it's true it wipes out all your kind of yeah it's true it's true thank you they have all kinds of problems they don't tell you to to to eat any yogurt to kind of replenish it and while there's good evidence to show that 1 course of antibiotics affects your gut flora for 7 years amazing isn't it amazing but anyway I agree I don't think you've really got any evidence of infection to treat you for I'm not sure what antibiotics I'd give you your chest is clear the selenium is a good is a good form of treatment for infection fine and do you take any other supplements you take selenium and vitamin c anything else well I do take other stuff mhmm I take brewer's yeast well I don't know the just the stuff I've never recall get the recalling when people kind of ask me these questions I like alison bread I don't like the white bread all the time no it's good to have some fibre isn't it are you losing your hair at all what you're losing your hair at all no you've got a lovely head of hair only because I'm reading about selenium overdose and it causes hair loss apparently oh really only an overdose you actually have a lot of overdose yeah 400 micrograms a day is quite a lot isn't it anyway apparently yeah you eat lots of brazil nuts brazil nuts are full of selenium yeah full of the selenium I feel like eating brazil nuts really oh I love brazil nuts they're a bit aren't they a bit dry anyway we've had a lovely chat I don't think there's a huge amount that will by being in the hospital but I will I would like to have you seen in 1 of our memory clinics if that's okay yeah yeah be we can have a chat about it completely soft no you'll be fine you're not too bad how will you get out of here how will you get home I'll probably walk quite a long way I would think it's only it's only warren where is it warren road warren road 55 yes a 45 minute walk yeah 45 minutes not too bad it's a fair way isn't it I was asked to run a marathon once and I used to work on the dust carts and I hope nothing got it mhmm because you know you you walk working on the dust carts you're working on a 26 mile walk every day really every day wow crazy if we called you a taxi to get you out of here would that be a good thing to do I'm sure we could try and find a way to cover it as a hospital to make sure you get home yeah for selfishly for me yeah I'll have a chat to my nurses to see if we can arrange that does that sound alright okay any questions anything I've forgotten no not as well I guess I'll probably in about half an hour's time think it that that that that well you can always call up and I'm here tomorrow and we can have a little chat sound good sounds good it's lovely to meet you I'll put you back up do you wanna come back at the waiting room not here but we'll try and find our way to you come home yeah sure cool it's 11:00 now so 11:00 let me speak to my sister's my sister the nurse in charge to see whether she can help us with some of things to get you paid is that alright well I wish I could probably speak to her it's a long visit isn't it it's quite long well it's good for you it is true how are you on your feet no how are you feeling on your feet come and have a walk with me have a good night and maybe just got it yeah cool I've been waiting for it don't even sit can sit are you sitting in a movie or you can sit wherever yeah of course I just don't sit in the don't sit in that 1 sit wherever you like it where you are and you'll find somewhere to why don't you sit just here and we'll find a way to get you out of the pit so hold on cheers I'm just going up to the toilet well you sure you're home I'm on the toilet now sorry has had a coughing yet so we're just testing it and see yeah so go ahead he lives a month and a half around in tolkien so at a 07:00 at night I've seen I've seen him really but if he's got they put him in bed that have a big breakfast in the morning and then great it's it's easy yeah it's easy it's it's easy it's family it's not the same I just think that's what it's I'm aware of yeah yeah was thinking that we might have an anti tech or something yeah well do it with the em to help us is that how we do no we we could do it but I just need okay as long as yeah somebody's given me the little budget code the budget code and the password I know it I know the 1 that you I'm sorry yeah but the ed 1 I know the password password but I can't remember if I did wait for it I think something oh so okay I'll inform lucy upstairs anyway there's do want me we're not phoning it yet just wait for me do wait for a minute and then yeah and then I'll yeah just want to get him to go to the hospital next morning okay I need to be awake thank you I just want want to I try and get him a taxi so amts score of 8 out of 10 he's 12 so we're getting you a taxi home are we warren road you've got your key and everything haven't you impression yeah oh that's good mild cognitive impairment with no acute clear underlying cause on blood test today to add tsh to blood test but the plan add tsh to blood test number 2 follow-up tsh marnay number 3 memory clinic follow-up as an outpatient number 4