Transcription - 20260210T 08-59.mp3

Patricia lamble 207935 hello hello I'm rob I'm 1 of the medicare insurance companies hello how are you oh I'm sorry good how's your breathing feeling not too bad not too bad no good no the doctor that saw you overnight matt told me a bit about you seems like he's looked after you very well yeah but your blood pressure was a little bit low so we were just trying to work out what to do about getting the fluid off right can I check your blood pressure again is that alright will you do it on this 1 because I've got arthritis and I see the other 1 when it's it's it's got it inside it's it's painful yeah of course if I can get it alright goes up can I a quick listen is that okay yeah thank you quite a shot now haven't you has anyone told you that you've got narrowness in the 1 of the valves in the heart before or the aortic stenosis yes yeah yeah when did you last have a jelly scan of your heart yeah and when that says you know that it was a very concerning ingredient and you know all the things that sort of a robbery and tell me about your life more generally who lives at home with you 1 does anyone live at home with you tell me about your life oh I live on my own mhmm I love the mhmm my husband died 13 years ago and I've been there oh I don't do very much to be honest and what stops you doing very much just the mobility really mhmm yeah and I ought to have moved after I lost my husband really the house is a lot to keep up it's no not at all was it but you stay because you've got a social life yeah well any options that's going because everybody's you know moving on like me either they don't yeah they're not sort of carrying on with the social life any hits or anything like that I well we did have a daughter but we lost her to breast cancer yeah so sorry she had 2 2 children got it I can't remember but they're up in the midlands I see yeah so but they're they're lovely they keep in touch all the time and do they see you very often well a couple of times a year but it's always long telephone conversations see right and do they know you were in hospital and things like that well I think that was going to get in touch with my brother-in-law to let them know what's going on yes well I had a long conversation with him the night 4 absolutely monday night so he knows you know he doesn't he because it it happened when I was going to bed mhmm I stood off the side of the bed when I was on drastic yeah I had a an alarm so I mhmm I started when they got the ambulance done and that's what happened today or yesterday well yes last night yeah got it yes then since you've come into hospital you've had lots of tests yeah we're concerned about fluid building up on your chest because of your heart yeah your blood pressure is still low it's 86 over 51 at the moment it's still a little bit low to give you any medicine to try and get the fluid off yes have you had a cough and cold or anything like that I've had a bit of a cough bringing anything up not a lot no nothing mhmm pain in the waterworks or anything like that no no fine no I cough it's because of a tickle know it's more than more than anything else yeah but I've never brought something up or yeah blood or anything like that no can I have a listen to your back is that alright would you be able to sit forward if not it's okay it's if not it's okay but more might yeah in 1 that's enough don't worry of course breathe in is that okay if it's alright yeah that's fine tiny ulcers yeah and the compression that seems to get rid of them nearly there yeah but I've got another week with the left leg and the right leg is almost ready to go it's oh wonderful stopping the stool it's quite tight bandages aren't they yeah and this catheter did we put that in that's in that's in we is that new for us yes it's yeah right so you're draining a bit of concentrated urine but there's not a huge amount in there right right I'll go and have a look at the blood test and the x-ray and look inside that and work out the best thing to do it certainly sounds like you've got lots of fluid on there yes but there's the potential that we're wrong and actually that's the effect of the rheumatoid arthritis on your chest more than that and it may be more to do with your heart that's causing this low blood pressure or indeed an infection somewhere let me look at everything on the computer and work out what's going on and come up with a bit of a plan sound okay we'll get you over to our acute medical unit and we can keep looking after you there okay yes it's lovely to meet you thank you see you soon sorry can you just put that back in the audience are you on track I can't hear any no don't worry connection oh no signal I'm sorry I can get you on the wifi if you want to text someone do you use whatsapp or anything no like it's okay if you pass through the tablet that's there I'll use that instead you know what it's like being in 2025 without your phone yeah wrong isn't it on so many levels no I was trying to break it down 1 what's your number and I'll try and get you on the wi fi it's 71734 yeah is it whatsapp that you use or do you just do text well no I was going to ravenhurst she's barbara but I I don't know whether this is whether the brisbane ambulance girls put my bags together I don't know if they put my spectacles in I'll have a look do you happy for me to write them through your bag is that alright oh absolutely yes you're on the wi fi there yeah I'll put you on the wi fi there if you want it's kind of them to put you a bag together isn't it you've got a toothbrush you've got your car keys there's some spectacles not gonna pass oh gosh she didn't put me in not on couch but they're there there yeah okay do you want me to put you on the wi fi on this or are okay no I'm I'm okay well yes please if you would of course yeah otherwise it's a bit isolating isn't it that's right yeah yeah same as what copy number 1734 34 yeah you're in very nice ray okay thank you worries you're very welcome yeah okay well I I'm gonna put the lower back give I'm I'm not gonna lie I don't know don't yeah we know if you've just 2 and 2 not 3 a or 4 a as in strict man by as or 3 or 4 a venous blood gas p 7.43 hemoglobin 97 euzenes creatinine 107 from a baseline of 70 potassium 5.5 and sodium 140 she's oliguric alp a 175 bilirubin 27 from 11 crp of 111 urea 9.7 inr 3.2 hemoglobin 104 mcv 79.4 a chest x-ray reviewed fluid in the fissure and right sided pleural effusion with associated consolidation left base relatively clear but some increased bronchovascular markings bilaterally impression hypotension raised inflammatory markers more consistent with infection than overload as a cause of shortness of breath continue plan continue meropenem slow iv fluid aiming map over 65 in the context of sepsis infection manage for hospital acquired pneumonia swab of bilateral leg wounds to guide whether these may be infected input output monitoring recheck potassium today is it no good awesome I've done 4 a's on that bit it'll work no suspend adalimumab for now alright so 4 4 a hematinics pattern on blood tests is consistent with iron deficiency anemia mister good to know it's fine not taking the best have to the investigations covid quad swab negative and blood cultures negative so far the reason for the review is highlighted by the night team as unwell with hypotension and element of diagnostic uncertainty

Medical ST5 Miller Review

Reason:
Highlighted by night team as unwell with hypotension and element of diagnostic uncertainty.

History:
Mrs Lamble is an elderly widow who lives alone. Her husband died 13 years ago and she has limited mobility. She lost her daughter to breast cancer; two grandchildren live in the Midlands with whom she maintains telephone contact. She has a brother-in-law who is aware of her admission.

She fell from the side of the bed on Sunday night whilst preparing for bed. Activated her alarm and was brought in by ambulance.

Since admission has been investigated for shortness of breath and hypotension. Known aortic stenosis. Has had recent echo (timing unclear). No significant cough, minimal sputum production, no haemoptysis. Non-productive cough described as tickle. No dysuria or urinary symptoms.

PMHx: Aortic stenosis, rheumatoid arthritis, bilateral leg ulcers currently being treated with compression bandaging (left leg has one week remaining, right leg almost healed).

Social: Lives independently but limited by mobility. Social network diminishing. Brother-in-law acts as main contact.

Examination:
BP 86/51 mmHg (hypotensive)
Chest auscultation: crackles heard bilaterally
Legs: bilateral compression bandaging in situ for venous ulcers, small ulcers present but healing
Urinary catheter in situ (inserted during admission) - draining concentrated urine in small amounts
Patient appears frail

Investigations:
VBG: pH 7.43, Hb 97g/L, Creatinine 107 µmol/L (baseline 70), K+ 5.5 mmol/L, Na+ 140 mmol/L
Bloods: ALP 175 U/L, Bilirubin 27 µmol/L (previously 11), CRP 111 mg/L, Urea 9.7 mmol/L, INR 3.2, Hb 104 g/L, MCV 79.4 fL
Haematinics: Pattern consistent with iron deficiency anaemia
CXR: Fluid in fissure and right-sided pleural effusion with associated consolidation. Left base relatively clear but some increased bronchovascular markings bilaterally
COVID quad swab: Negative
Blood cultures: Negative so far
Oliguria noted

Impression:
Hypotension with raised inflammatory markers more consistent with infection than fluid overload as cause of shortness of breath. Hospital-acquired pneumonia most likely. Diagnostic uncertainty regarding contribution of known aortic stenosis and possible rheumatoid changes to chest findings. Acute kidney injury (Cr 107 from baseline 70). Iron deficiency anaemia. Healing bilateral leg ulcers.

Plan:
1. Continue Cotrimoxazole (not Meropenem as previously documented)
2. Slow IV fluids aiming for MAP >65 mmHg in context of sepsis
3. Manage as community-acquired pneumonia
4. Swab bilateral leg wounds to guide whether these may be source of infection
5. Input/output monitoring given oliguria
6. Recheck potassium today (currently 5.5 mmol/L)
7. Suspend Adalimumab for now
8. Transfer to Acute Medical Unit for ongoing care
9. Iron studies and consideration of iron supplementation for anaemia

Summary

Investigations

Plans