Transcription - 20260201T 22-49.mp3

No we're looking after you don't really know I'm not sure why you're here okay yeah are you any have you got any symptoms at the moment to speak of no not really no how about that tummy discomfort that you had before no no no nothing like that no nothing like that no any chest pain at all no definitely not no okay that's fine and I hear you've had some loose stools is that right some diarrhea no no you don't think so fair enough fair enough I'm gonna be giving you some fast fluids I'll just clean it up a bit just like very quickly okay then a little bit strange is your markers of infection in the bladder at home I suspect you have an infection somewhere as you're quite aware maybe in your urine maybe in your bile ducts not completely sure no and tell me about your life more generally who do you live with at home can't believe it I'm part of the I don't know by yourself yeah where do you live I live in melbourne here in melbourne beachdale park which is a park only place isn't it is it nice there it's not so very much any worse no sorry you can't no problem and you don't need what do you do with your time what did you do today for example well I don't know coming don't know I just I just friday friday friday friday generalities generalities yeah generalities and generalities generalities how much are your hands do you smoke no that's good do you treat alcohol no alright you do lots of manual work with your hands no do you like chocolate no anything you do like can I have a listen to your chest please please alright yeah and I can just listen to your thumb is that okay yeah I can't hear you sorry but she shouldn't even be around I just is sat he's been down by the first system still in the past and I'm just a little bit just crying I'm crying does that make me feel sick no good really nice to hear no you're cranking yourself in your eye yeah no I'm not I'm just you're flu okay give me a bit of fast fluid we're carrying a few antibiotics if you're wrong alright get your blood pressure on it better and you'll feeling better you're gonna have another blood test now just to make sure that everything's looking okay okay okay I need to see if I can get blood done I'll probably do it once a the care so that's the reason why at patient's care system so you know we're at our results so we're looking at the care system so we're at health care system system so admitted to acute medical unit yesterday review of previous notes on review yesterday was tangential unclear historian unclear presentation cause multiple wide differentials for what was going on subsequently he was discharged and then represented after he was found unwell by his neighbors so reviewing previous ed notes - dot osteo ward round from day before yesterday reviewed difficult to put together previously he felt that his previous delirium was a psychological event and recovered to normal level of independent function seems like he did a lot of physical work on the thirtieth the 20 ninth of the of january I should say made himself some food was hungry felt unwell with a sense of physical work lifting and shifting tables to the back of a car sawing bits off the legs made himself some food hungry to eat then became then began to feel unwell with a sense of unease and pain in his left upper abdomen and epigastrium which became more severe and moved into his back became constant analgesia wasn't helped the team yesterday and doctor miller from the post op ward round yesterday was concerned about acute episode of something possibly biliary colic possibly pancreatic inflammation possibly a vascular problem like an af embolism to the sma possibly a splenic infarct and then it seems that after a day of admission he was discharged and then represents today more muddled more unwell with now development of hypotension which is responding to fluid his blood tests are compatible with a biliary infection possibly cholangitis although his ct scan didn't identify any source of this but did show some pancreatic inflammation which could be consistent with a stone ct doesn't have the best sensitivity for picking up ductal stones but does have good sensitivity for picking up ductal dilatation which he didn't clearly have it is similarly unclear to me what is going on but it seems from the look of his blood test that he has developed an infection probably a biliary infection but urine infection is also a possibility he's on appropriate antibiotics for that he's febrile still and becoming more hypotensive so we're gonna give him some fluids some paracetamol and give him another dose of tazosin which he was due anyway I will flag him to the night registrar so that she is aware of the nature of his presentation and the possibility of continued diagnostic uncertainty

Medical ST5 Miller Review
23:00

Developing hypotension, presyncope on standing.

Review of previous notes:

Examination:
Chest examination normal. Patient febrile and hypotensive, responding to fluid resuscitation.

Investigations:
TnT 150 - vehemently denies chest pain at any time since admission recently but is an unclear historian. With concom

Impression:
Continued diagnostic uncertainty but biliary infection with delirium seems most likely
Raised TnT - most likely T2MI secondary to infection given lack of chest pain, I think that the cardiology team would not intervene in the absence of chest pain
CT scan shows pancreatic inflammation possibly consistent with stone passage, but no clear ductal dilatation. Blood tests compatible with biliary infection.

Plan:
1. IV fluids stat
2. Paracetamol
3. Continue Tazocin (dose due now)
4. Flag to night registrar
5. VBG and TnT repeat
6. Aspirin 300mg PO stat - clopidogrel considered but potential for biliary intervention needs to be balanced with this. I think that MI with obstructed coronaries without chest pain seems very unlikely so I don't think there is a role for DAPT now.

Summary

Investigations

Plans