Sally connolly 305468 72 year old lady observations temperature 37.3 has been afebrile since presentation heart rate 105 respiratory rate 19 blood pressure a 135 over 98 saturation is 90 4% medications list note recent course of amoxicillin on the february 6 for exacerbation of copd but unclear if prednisolone was given alongside it sertraline 100 mg once a day metformin 1 g modified release once a day pregnosalin 5 mg once a day doxycycline 100 mg 3 times a week monday wednesday friday the ical d 3 1 tablet once per day ventolin inhaler salbutamol nebulizers 4 times a day atorvastatin 80 mg in the morning doxycycline rescue pack sodium chloride inhalation solution twice per day as nebulizer trimbo 87 / 5 / 9 microgram per dose inhaler 2 puffs twice per day zoledronic acid infusion started 2019 isomeprazole 20 mg once a day becomelomethasone nasal spray 2 sprays in each twice per day carbacistine 750 mg 3 times a day ezetimibe 10 mg once a day aspirin 75 mg once a day or ramipril 2.5 mg once a day past medical history uses was previously housebound however can now get to shipi shipi on her mobility scooter depression osteopenia heart failure type 2 diabetes mellitus with retinopathy copd osteoporosis myocardial infarction 2008 asthma coded 19 94 probably just start with doing that but I think what we're doing 2.5 is then we have another 2.3 nebulizers the tylenol nebulizer the tylenol is not good so if you just give it all of them then it will still yeah it's still got a lot of oxygen force saturation is 92% on air when seeing respiratory nurse you can get a half strength 2.5 so it's the same volume as the 5 that's what you need to do and that's why you need to fix it do the the the right still happy yeah she's the I'll look at him says like I don't most recent digitally available echocardiogram 20 22 april poor echo subject apical views only overall mild reduction in lv systolic function no significant valve abnormality changes if you give some antibiotic or not right it's yeah it doesn't need investigations ph on admission 7.27 on a venous gas with lactate 5.4 and base excess - 5.3 with a p c o 2 of 6.3 in the venous system subsequent arterial blood gas demonstrating ph 7.38 with pco2 5.7 and base excess - naught 0.4 rapidly improved with lactate clearance has now lactate 1.7 sodium 142 potassium 4.7 creatinine 51 at baseline liver function test crp 2 urea 4.8 ast normal full blood count hemoglobin 113 with neutrophils 10.52 and white cells 20.4 normocytic anemia copy that across thanks mate note recent respiratory culture on the february 9 when she was on mccollum ward so attended ed on the february 6 with sudden onset shortness of breath and wheeze started her rescue pack on arrival sats were 86% hydrocortisone given and she was admitted under the medical team but unfortunately there's no discharge summary under doctor diggins on mccollum ward she was discharged on the ninth of the second so yesterday and then subsequently presented today great thank you I've heard these things I've heard it properly so if you haven't stay for the same I just wanna get up to date with this and chest x-ray clear lung bases possibly some hazy left basal opacification but unclear hyperexpanded film rich recent chest x-ray february 6 demonstrating clear lung fields at that. As well hi sally I'm doctor tom I'm rob I'm 1 of the medical registrars it's nice to meet you how are you I'm alright yeah I hear you're in hospital recently you came in on sick you were on lovely macallan ward my own what happened yeah went home this morning no yesterday evening oh yeah yesterday evening yeah okay well it's 09:50 in the morning she's so you went home yesterday evening then what happened yeah you've been fine and then I woke up in the night and I breathe mhmm yeah suddenly couldn't breathe did you have any pain in your chest or anything like that no just suddenly I just woke up and I was like yeah funny isn't it yeah fine good it's fine using your inhalers and your nebulizers at home use them all the time use them all the time still smoking or have you stopped now I haven't been up to 10 years great good time lasted how long did you smoke for it nearly started it was in my twenties mhmm about 22 and I'm more 46 so I'm not 46 72 mhmm you're fine and a pack a day over that time maybe maybe not more than that probably very good and any swelling in your legs lately or anything like that no I don't know if my ankles have been a bit puffy but mhmm that's about where they are now and you're needing a little bit of oxygen say 2 l of oxygen if I turn it off just wanna see what happens to your saturation because you're a 92% with no oxygen with no oxygen with some oxygen I should say and we want you to be between 88 and 92 you were 92 when you saw them in clinic when you were well yeah when you last saw the respiratory nurse so let's just I'll just carry on examining you I'll keep an eye on the ones that we're be fine yeah that's your normal exactly just look at your hands if that's okay and so you don't smoke do you drink alcohol does anyone know that you do no just by yourself yeah I'm clean don't smoke clean living yeah right alright and what do you mean when you say you don't go out is that out of choice or you just feel too poorly to go out yeah I think it's a hard choice for you out of choice not really and when did you last get out of the house yeah and I've lost good stuff you got mobility scooters before yes that's good I don't stay in all the time I haven't been out for a few weeks but I think it was the weather as well it has been crap it's just brutal tell me about that you go out on your mobility scooter how far do you go it goes down to the beach lovely yeah to whereabouts so I don't know to hampton beach I haven't been to my local co op okay yeah fine so you go and do the shopping yeah and how do you get the shopping the rest of the time when you're not going out and you're online and getting delivered yeah and does anyone help you around the house okay it's gonna be difficult to do the housework with you breathing like this yeah well I've been helping you on a wednesday okay once a week someone helps you with that I haven't really been this bad I've been I have to try and do as much as I can mhmm yeah I'm running for fun I have to get somebody down yeah so you didn't have anyone coming to help you at home for all of this only on the wednesday on the wednesday once a week yeah alright and she does helps you with housework and like that yeah she did the bed yeah mhmm and her bed things like that just like want it hard when you've been doing it all day you find it hard mhmm just to still no of course it's different when right now I know I couldn't do it but when you're being a 100% I mean I mean I just need to learn to but yeah of course I just think of it the monitor so it doesn't beep at the front it might make you slightly more setting I know so why is my 2 so off oxygen you're starting to go down to about 87 okay with us chatting so I'll pop you back on a tiny bit just 1 l now instead of the 2 you were on before and we'll see how that goes in the night is that alright alright your blood test when you first came in was worrying that it's got much better oh see which is good oh we found it to be upset your blood was quite acidic and you're worried that you weren't breathing enough but on the subsequent test you're breathing just fine it was probably a combination of not of being very short of breath and breathing really hard because you were so wheezy I know what's breathing hard I know and does the wheeze feel a lot better since you came in yeah still feel a bit still feel a bit wheezy yeah and any fevers or cough and cold lately no you've been coughing more than usual no I haven't been coughing mhmm I've been on the ward now and they're all coughing so I've got the ward yeah that's true yeah yeah fair enough gonna have a little listen to your chest is that alright okay we'll start from the front gonna touch your tummy any pain in your tummy at all or anything like that just a bit there yeah I think it's not quite helpful yeah yeah how are your bowels and bladder doing yeah they're doing fine good good can I have a look at your legs yeah I earlier there's no swelling on your legs or anything like that no any rashes or anything like that really hot air no you got a bit of a bruise though is that right no you take steroids every day is that right tell me about that is that correct need me copd for your chest yeah but not for an inflammation in your joints or anything like yeah but I've been my ankle was walking out on me for 3 months got it and now you're on the alendronate infusion to keep foam strong and make sure he's got that high and I paid a fortune because he doesn't have to fight so yeah of course I think I've got down to 3 3 but sometimes know I only get to this and then I start to flare up again and 3 being 3 5 mg tablets you're on 15 mg now now at the moment that's what you came in on mhmm oh did I no is that right is that what you're telling me you're taking 3 tablets I was taking them yeah I'd put anyone in yeah so so when you're in the hospital had a unfortunately there's no discharge summary but I'm assuming they gave you a high dose of steroids yeah yeah yeah 30 mg for 5 days before yeah no I've got that thought I was on that a long time and then you've now tried to bring that down you were on 6 as you say which is 30 mg yeah yeah you and brought that down to 3 and that was before you came into hospital before is that right yeah and then I got ill yeah of course I got sick yeah think so your blood test is much better which is good so you don't need to be in this highly monitored environment which is great so we can step you down to somewhere a bit nicer and more pleasant to be and we're trying get you to our acute medical unit so we can keep looking after you there or indeed back up to mccullum ward where you were before because they know you're there how long ago am well you're needing oxygen and that's what keeps you in hospital unfortunately you're still very wheezy if we can transform the wheeze then great but it doesn't seem like what we did last time was very effective so no wait wait why don't you just get like an a fine window yeah fine window mhmm because I knew I wanted to go in the bed mhmm but nobody was gonna have to wait till I see yeah yeah sorry we'll do a meal we'll do a marker of damage to the heart a troponin sometimes that can make you feel very short of breath get some magnesium up which will dilate the chest a bit and we keep you on those nebulizers to break the wheeze and get you feeling absolutely you don't need antibiotics because there's no evidence of infection on your on your blood test but I'll put your steroids back up to 30 mg to try and help with the wheeze as well any questions or anything like the problem no I'm very good you what do you want me when people come into hospital I think it's always important to talk about resuscitation and what you'd want if things were to go badly in hospital work to improve have you talked about it before no no what do you think I don't think it would to have happened no I wouldn't know either I think if with your chest the way it is the chance of having a significant disability and being a lot worse than you are now if you even survived after that would be very high I think it's about what kind of quality of life you'd yeah want to fair enough that sounds good I'm trying to but I do not know I think it's good to give you treatment on the ward good to give you a tight fitting mask if required through low air review what we call noninvasive ventilation like that yeah it sounds like that should stay quiet alright any questions about that or anything like that no just that I thought that there was a must really effort otherwise know you were in hospital I'm so sorry I was so sorry I stressed I was like know I I guess what we don't want though is ringing your home and thinking where why are you not answering sorry that's true that's right yeah it's important I know that she's got a lot going on but yeah I like to message her yeah have you got your own phone help you yeah have you got your phone do you want me to give it to you so you can message her because I know if I called my mom and she'd pick up I'd be quite worried in medicine you happy for me to write them through your things I would like to I've got a lovely handbag in here I can get 1 too can get 1 too okay okay so how are you yeah you're there was a bit of time I went on it my god it's so weird brilliant so you just really the smell was just too much on it and then yeah but you just get used to it don't you I've got that it's not funny but you do you go a bit nose blind don't you is that right right bit of that I reckon mhmm now it's the end of my back hello hello okay there we go oh this is gonna be good so the whole scan of the penis is gonna my mom's the same when you fall asleep so whatever you say how fair is it because we grew up with all this stuff it's this world that you're now in with all these people that are trying to get you all the time and it's just not normal is it no I I never friend or I I don't want them all mhmm no don't you think you need yeah doctor in a high degree I do but it's different when it's your oh here much as yeah even like now between 8% yeah but just after this funeral the whole lot yeah you know that's yeah the 80 year old yeah and you put all of your all of your energy into your kids don't you I've got so much yeah it's kind of by living by living your age garnt yeah nice to go to gym australia you're also airway in cape town yeah is it it does hurt a little bit but it's not really going on with it yeah so you've got expansion he's a bit palpated oh it's stopped now I know that's coming percussion yeah so okay and where else do we need we need this gone don't we it hasn't been everywhere but it's not changed your life just run on their own don't they they do all you wanna do is get some senior phone up then they installed each other and then it's all for us it has to be yeah I just wanna use something nice to do it what would be a really urgent thing to know about though chester do you kind of gave for it or don't protection for the anesthesia what's special matt so I've got special yeah and then what are you looking at in terms of sleep it's quiet yeah it's nice yeah yeah I mean that's quite nice you what's big for you you know well it's cold to be fair but it's just everyone's cough some good people looking after them sweep if without drinking a mountain so if the armpits on there they'll be they'll be stripped down all the scissors are gonna be stripping the kidney out between the 2 and a half but she probably don't get all that 1 she's on there does she no it might be like oh it depends what you're wearing and that under yeah probably yeah and I'm just checking the volume this was good and we're just fixing phase so that we can call families how is your back over for you this morning that is so nice we don't really know today fantastic you should wear the blanching with everybody katie I don't know what I've done on that is that we don't she's fighting with some friends oh yeah do you wanna send her a message is that a remedy I don't know whether to worry or not I don't know if it's got the best time to do it yeah but I think it's important to know what's going on yeah yeah I can't do it yeah alright alright so plan is well it's already done