Marianne jeffries 475658 51 year old lady past medical history stage 2 hodgkin's lymphoma 19 96 managed with at the age of 22 he's much better underwent prophylactic bilateral mastectomy with breast implantation and metissimus dorsi flap full stop later developed supraclavicular fossa mass thought possible to be lymphoma but subsequently identified to be a schwannoma in the left supraclavicular fossa 20 13 which was resected and demonstrated benign peripheral nerve sheath tumor with the features of a degenerate schwannoma it's possible that it was secondary to her previous medical radiotherapy this develops hypothyroidism and takes levothyroxine following mantle radiotherapy and also takes hrt has 2 children both cesarean section deliveries current issues evidence of myocardial ischemia with troponin ts rising to 969 but echocardiogram normal fine so now let's talk managing food deranged liver function test with hepatocellular picture alt 2,483 with developing jaundice bilirubin 39 from previous normality bilirubin more than 4 patients per day alp normal ast 2,177 think leptospira screen awaited creatinine 90 from 77 developing acute kidney injury but normal electrolytes crp is 9 inr 1.6 without anticoagulation from 1.1 hypothermia and hypotension refractory to fluids lactate 4.2 on admission ever gastric and left iliac fossa pain ct scan demonstrating bibasilar pleural effusions ascites periportal edema bibasilar ground glass changes incidental left mammary nodes of uncertain significance note had breast mri september 2025 where nodules at that time were slightly smaller well they're smaller now than they were in 2025 actually no pulmonary embolism no internal mammary lymphadenopathy perocalcitonin normal hcg negative there I'm I'm enrolled on 1 of the gastroenterology stis and I'm a medical registrar on call this evening the consultant just asked me to pop in and say hi to you just because there's a bit of having sort of explained kind of diagnostic uncertainty as to what's actually going on yeah and there's a bit lots of findings and lots of blood tests and they're just trying to get all of the various people on board to see you and try and watch out what's going on it's bit weird isn't it it is funny yeah it's just weird but we like weird things yeah we're interesting is he is he I don't exactly but and you're doing fine you know your numbers look much better yeah they're really looking after you really well so you've got time to talk and work out what you think was going on that's it yeah yeah do I understand you're down at mount sands down at mount sands it's yes it's very lovely I proposed to my wife on mount sands did you aw she's from brigham so she takes that yeah yeah I was thinking better sorry I think it was good apparently it's big yeah oh nice I love that and you were down there sir maybe I'll see you down there sometimes yes yes I can ask yeah so I'm pretty well happy I yeah did you catch any waves yeah yeah did good because I've been surfing for like about 6 months it's probably a bit too much more if I've come to the first time back probably a few hours you know because you have to walk a big walk down there yeah a shit walk back as well with the board over your head with the board over your head having a few little meltdown problems in so my tell me all about it you're feeling well and happy and this was on the 20 ninth was it yeah yeah we went down new england bridge there mhmm went down to radsound we went down you parked in the national trust car park no we parked up there's a farm there oh yeah we parked in that little lay by here yeah and I walked down very fine yep no travel surfboards yeah surfboards fine yeah surf I've got to get out just to go and talk to my friend for about 5 minutes mhmm you know you feel a little bit gasped but I've been supper for a long time yep so went back in I was fine so how long were you in for in terms of you a couple of hours mhmm and in 2 separate sessions kind of thing we came out and chatted for a bit well oh not really it yeah okay yeah and a wet suit on wet suit suit yeah pretty good I don't well I've got another problem good but pretty's gloves wet suit yeah yeah so I have felt fine a bit of a cold going in sorry just pop that on down sorry and then things looked bad then my friends they were so upset before her face oh gosh her own support was someone else's yeah oh nice yeah yeah better than me so then we got out because it seems that the shoes felt really she thought she had really done something so it's like walking that way you're pregnant is she does she work in the evening too no no no she's she's quite she's quite of stuffy as well yeah you probably know if you that was my second and yeah so we walked like she walked ahead I was just walking ahead because I was I was feeling a bit tired and then I was very much just like oh I was suffering just could not I was just like no energy so you got on the water okay yeah and then you're walking up the hill yeah and you felt tired tired how else do you feel just busy mhmm just I kept stopping mhmm I don't know my mind is offered to carry on board I said no I'm fine mean nothing was so independent the other way I would have said the same thing yeah yeah and then that sort of got to the. Where I was like I couldn't I just had to sit there and just and I was so you just stopped on the side of the road that that dodgy road on the way down yeah yeah on the walk on the walk up mhmm yeah you stopped on the path sort of passed that every bit I've got to try to get it tied together you felt dizzy and light headed dizzy and light lightheaded and I thought right do you feel cold yeah no yeah I thought you and then I'm like right I stand up again and try I just couldn't I was gonna try to pull up couldn't pull up and I just sort of sat there and then yeah stella came back down they sent me to me was like oh yeah and then lovely we're quite out the top you knit and so the ambulance just came from fine then you got picked up there early and then when they picked you up they found you to be quite your blood pressure was quite low you'd be quite cold oh well yeah and they brought you to eat it garlic as well right yeah yeah and we all thought this was I think just high bay thermal injuries yeah yeah don't eat too cold yeah did you walk up and down in your wet suit yeah yeah it's your fine I'm like how can you get cold in a wet suit it's fine isn't it actually in the end I did take the top half down so I felt a bit claustrophobic mhmm so I don't know if walking up yeah I don't know if that walk up isn't it and I didn't know if that was just yeah because of yeah yeah it's about your team generally as opposed to anything else yeah yeah of course yeah alright okay fair and then they've gone and got me yeah and then correct your history and your residency and then you then I'm sure the teams are looking after you so well at explaining about the tests you've had and everything that you've found since you've been in mhmm and like both those are fluid according to you because your blood pressure was low in the morning and then and how did you have any symptoms there did you have any pain anywhere or anything like that I mean I had when I was walking out I had pains in my shoulders and stuff shoulders like achy achy because it's when I was throwing the ambulance I did say it could be a cardiac thing because you because of the old rapamediate you know what's going on yeah I said you know it sounds like it's quite well they got that quite quick but in ed they do increase my blood pressure which is because they were doing discharge and everything that's too bad for them they're yeah did paramedics go no did oh really god what because they wanted you for the shift later it was on 1 hand so it worked for us that's a real 1 I don't know cool yeah me too and yeah no I mean I I was I was being sick and diarrhea yeah that's it I thought it could have been drinking like some water as well did you think about the drugs this morning I think it yeah were you getting tumbled over a lot yeah mhmm yeah and we were celebrating so I was pretty sure yeah fine that's fine it a couple of hold downs and things like that have you said were the conditions quite thick not too big but it's yeah it's because I'm weak you know it's just it's it's funny talking about surfing think I've got very excited yeah no sorry yeah but the ned I did to him got obviously busy when I was standing up mhmm and everything mhmm and I was like no I'll I'll go home yeah because you're yeah yeah got it so I said go and tell them my blood pressure's okay well they said you can go around and I was like give me my blood pressure after a lot of shit yeah you can't tell them I was blessed yeah but my heart rate was a lot less yeah about the days before you entered the circuit how are you feeling alright normal yeah I mean I've had like I need to sort of go to my people with loads of stressors here k so there's lots of like just stressful situations there but not yeah and it's just a big dizzy spells and stuff like something that's been busy mhmm but nothing you know extra no mhmm okay and did you have muscle aches and tiredness before of this or no really no no I to the gym and stuff like that right I was gonna ask about you like more generally you work in ed you're usually a great fit and active don't think I understand yeah so you go to the gym go to gym live with at home my 13 year old and my 24 year old mhmm fine yeah drugs alcohol cigarettes alcohol a bit of alcohol yeah how much alcohol just a yeah yeah I know it's usually alcoholics a lot so I don't want to be 1 of them no I know yeah fine alright and no illicit substance either no no cool okay you're not allergic to anything are you no not at any level no fine okay and obviously you I read all I've been reading your old notes now back in the nineties you had constitutional lymphoma you had radiotherapy to your neck and mantle yeah to treat that and then you had breast surgery following that because there was a risk of the potential of inducing a cancer because of the radiotherapy and then you had a schwannoma on your shoulder that they cut out that gave you an elder nerve palsy that then got better after the schwannoma was exposed it's still a bit of a smack but you know it is so you've been banging good stuff the job yeah does the job great and then no other medical problems then of course said no no you take levothyroxine after the hypothyroid after the radiotherapy you take hrt yeah and you take it there's a cream hrt isn't it yeah and nothing else no fine no supplements sometimes just the exercise can make you a bit yeah reflux yeah yeah fine and supplements and extra stuff for the holland and barrett is that kind of your thing yeah yeah you like all of that tell me what kind of stuff do you take I've got the n m m is it is it it's a precursor to that yeah fine I've been taking that for a long time mhmm well I've I've got 100 and barret lately I've had my but it's usually just with vitamin b the little b 12 sprays and vitamin d mhmm that sort of thing yeah okay yeah the usual kind of stuff but it's not a weird and wonderful thing isn't it no yeah steroids no not really no I can't yeah right all that you're natural good yeah can I examine you do you like yeah no no I just use your your personal stuff okay even though I've got mine out there I've got a bad idea that's all thank you comments to time I've always had a profound I think sounds good listen to the heart mhmm and listen to your nose around the ear good for that 1 the ready okay good so I'm feeling the coughing like aye get off the wrong way okay that's okay sorry think that no that's alright yeah it's alright yeah okay so we're getting on the side and stuff you're going down to your left hand side yeah down here mhmm and your bowels are or 2 I'm fine well we've got the catheter yeah yeah because it's stuck in bed because of the blood pressure yeah yeah the bowels have over the next day mhmm okay and tummy pain wasn't really a thing for you before you came in no no okay do you mind if I get an ultrasound machine and have a look at your pancreas yeah okay I have a scan of these tongue which is very good for that sometimes they can pick up tiny bits of grit better an option that's getting weaker and you're very fit I think I'll get good for you I'll just go get the machine is that okay yeah yeah yeah thanks you got to stay dating off go what have I done no my trouble I'm not using it I was hoping to borrow it off I shouldn't oh do have 1 then with the abdominal cradle that's the problem it's just kinda weird just kinda a curvy a wrap okay on examination regular bradycardic peripheral pulses no hand signs chest examination no rashes tongue dry no focal neurology identified on brief neurological examination abdomen mild epigastric tenderness on deep palpation bowel sounds present no peripheral edema bedside upper abdominal ultrasonography good volume liver no evidence of chronic liver disease portal vein scan looking normal bowel ducts interrogated in detail no lithiasis identified poor views of the pancreas due to overlying bowel gas however no clear echogenic foci seen impression most likely multiorgan dysfunction secondary to hypothermia secondary to prolonged surfing with ct findings secondary to fluid resuscitation due to low blood pressure however persistent junctional rhythm and rft derangement raises possibility of multisystem disease suggest extensive panel of investigations to exclude alternative causes viral screening hepatitis a b d e cmv ebv vzv parvovirus b 19 hiv ceruloplasmin and transferrin saturation as autoimmune liver profile anchors immunoglobulins add ck to blood tests it's not yet tested as far as I can tell 9 am cortisol monato exclude adrenal insufficiency as a cause tsh and t 4 cents and awaited I will discuss with my consultant and ask her whether she might be able to come in to see her tomorrow morning