Jeffrey noble 285338 72 year old man yes can't deal with any untidiness yeah well I always think I annoy people when I've been in here because I've tried to like all the sleep stuff while I'm there I'm still gonna get an mri certificate and I do like a thing flushed in everything's ready past medical history urine retention and intermittently self catheterizers admission with community acquired pneumonia 2023 polycythemia rubra vera background diabetic retinopathy secondary to type 1 diabetes mellitus diagnosed in 1992 medications list so that was oh sorry so lisinopril 2.5 mg once a day tovastatin 20 mg at night lantus and humalog insulins venous blood gas lactate 1.5 glucose 12.4 sodium a 132 ph 7.35 renal function normal liver function test normal crp 1 urea 7.2 ast 21 full blood count normal so in the history of standing plate stood up at the teaching table took a step back woke up on the floor wife witnessed the event falling backwards onto the floor came around straightaway lost consciousness for a few seconds checked his blood glucose which was normal at that time move to recess put on cardiac monitoring given some atropine which improved the heart rate to 75 to continue on cardiac monitor heart rate 33 okay so your blood pressure's here you've definitely got some some evidence of fluid on your lungs which should happen when you're on the last set but you've got good a little bit of puffiness in your ankles any pain in tummy have had pain in feet but not me no and what did you have done do you had a gallbladder taken I have had a had gallbladder yeah that was a long time ago 21 yeah goodness we don't tend to do that much you know that anymore no do a key hole yes they are fishy holes so it certainly sounds like you've got some fluid on your chest that can happen when your heart's going too slow mhmm we've got various things we can do about it but what I suggest we do is put them on a drip of a medicine to speed the heart rate up what we call an isoprimidine infusion that'll keep the heart rate at a nice normal rate and allow us to bridge you to get the needle to do a pacemaker to sort you out is that all right give him something like that give you a exactly a medical patch key which worked very quickly but then comes off very quickly so what it did stabilize things improve your heart rate temporarily but didn't get it didn't transform it and it certainly seems like you're back into a complete heart we'll get another tracer in the heart now and just see how it looks alright thank you come back in a minute so you're taking a look at his mouth we'll take a look at mouth we'll now on examination he's got normal heart sounds with bradycardic he's got regular bradycardic peripheral pulses he's he's got bilateral bibasal fine crepitations almost up to the mid zones he's not got any peripheral edema he has a no abdominal tenderness and it's soft but he has a right upper quadrant scar consistent with previous open cholecystectomy plan is discussion of cardiology isoprenaline infusion to maintain heart rate given evidence of heart failure for consideration of pacemaker