Recovery in your dream that he's now having some ups and he says every 90 seconds or so not someone we know jeffrey tompkins 93 year old man 548198 3 yeah okay you is there a trolley in there number 1 no turn it out bring this 1 down past medical history cholecystectomy 1990 him him k him small bowel obstruction 2021 bppv hypertension ckd 3 colonic divert iculosis ischemic heart disease with coronary artery stenting july 2020 primary open angle glaucoma with you and make sure that's all you can do so what I'm doing at the minute is yeah a watchdog it's so the cardiac background is of a uti stage primary coronary intervention to o m 1 2 times stents july 2020 previous elective pci to the right rca distal / mid lad 2 times stents for ccs class 3 angina june 2020 bystander distal lad and distal circumflex disease for medical management fractured neck of femur 20 19 dhs walk slowly with aid of a stick that makes it easy sigmoid diverticular knees the way you find this is you literally go on to Google and then medications list anadronic acid 70 mg once per week thei cal d 3 1 tablet once per day frizanide 20 mg once in the morning atorvastatin 40 mg once in a day aspirin 75 mg once a day omeprazole 20 mg once a day latanoprost eye drops once to be used in both eyes once per day 50 micrograms per mil and lisinopril 10 mg 1 to be taken each day investigations list hemoglobin 113 previously a 115 and and a 109 in february and june respectively crp awaited coagulation screen awaited venous blood gas normal troponin t 397 and 207 former at o 06:23 and the latter at o 02:48 blood tests from 9 then 05:00 in the morning full blood count normal euzenies yeah then creatinine 156 from previously 128 in november 2025 mild aki okay aki stage 1 itch new function test normal apart from alt of 50 when was previously 9 in june 2025 crp less than 1 urea 16.6 ast 53 chest x-ray clear lung fields mild left basal haziness at the costophrenic angle and impression of increased bronchovascular markings bilaterally compared with previous x-ray 2023 previously atelectasis in the left lower zone as well so stable appearances compared with that a ct thorax abdomen and pelvis in july 2023 with an indication of trauma which demonstrated background fibrosis which had progressed compared for ct 20 19 cardocystectomy noted liver cyst noted heavy aortic calcification atrophic right kidney fecal loading in the rectum uncomplicated colonic diverticulosis bilateral hip replacements osteopenia degenerative changes in the spine no rib fractures I'm just gonna find out where we are now can you feel that walking start to work so jeffrey tonka's observations heart rate fluctuating between a 160 and svt and reported by the radiographer and the radiologist once they've had a look at it 94 9 to 95 in sinus rhythm respiratory rate 23 blood pressure 102 over 77 and saturations 97% on air so history from triage 3 episodes of chest pain today latest at 10pm read by the acs nurse chest pain on exertion for the last year goes after 10 to 15 minutes with rest now getting on any exertion yesterday woke at 08:30 to 09:00 09:30 in bed at pm and developed central chest pain like squeezing radiating into the back hot sweaty and clammy lasted approximately 1 hour subsided oh actually that was the morning o 08:30 to 09:30 in the morning then subsided all day went out for coffee and then at 06:30pm another episode which lasted a few hours went to bed felt like he couldn't lie flat as he was coughing pain returned at 01:00 in the morning called for help and the wife persuaded to come to hospital well known to cardiology because your lungs are flat your oxygen level has been quite high and you're able to a of fluid in toilet hi this is tom fitz and welcome to medical doctors nice to meet you you've met the a and e team who've been looking after you yeah but there's talk of you coming into hospital for a bit more treatment for your heart yeah so they've just asked me to come and see you just to make sure everything's sorted for you to be in the hospital is that alright yeah yeah yeah fine I understand you've been having some pain in your chest since yesterday in the morning you were having some intermittent episodes is that right yeah was a few days in the morning mhmm yesterday I was did you call it a day later I think today yeah actually what time did you have the pain today just before I came to the mhmm on the other ward just the nurse come in just prior to that I spoke and told my boy on the phone mhmm and talking to her he called her out you know so it's your wife's fault really that's it and you've been having trouble with this chest pain for the last year is that right oh yeah I had some stents put in at but 1 it's not a good pain it it it came back again I went to the doctors and I could walk so far mhmm but after that I'd finish up up and walk any further I've already given some tablets for all of and what stopped you from walking I just get out of breath get short of breath do you get pain in your chest as well or it's primarily no it's a discomfort in your chest any pain in your calves or anything like that no no so no claudication sorry mhmm I'm I'm in my tore with my toes at the moment oh why is that I can do a cristeropathy oh fine I would call ben down yeah of course they're a long way away so get them our nurses might be able to talk you I read about that too you've got both sided hip replacements on that top of my shoulder on the other side but since then more like on the inside oh I'm sorry because you're able to because you walk with a stick is that right I don't walk I can walk a bit without it actually oh great far I get out of breath mhmm it's actually because of the heart mhmm well I what's really remaining of anything with my eyes the glaucoma well it didn't I started to hardly 3 times already mhmm and all of a sudden someone comes in the vision yeah and it goes and the loud noise comes in not a big bang you can hear the bang yeah or it's mhmm what about does that and it comes back in again right but when it comes back here to see absolutely oh the girl was on the on the counting office didn't do anything there it was like that every choice the whole of your vision was twisted yeah so you get these episodes yeah where you you've noticed there's something in your vision is that right yeah tell me what what do you notice it's just no it's just a bang it seems to me I think there's something in me and to see you I've given a spite speak to somebody yeah and it just it it is how it breaks off you know it burst okay that's what we're talking and the the sand comes in it comes straight back again yeah but I I can but it's done it a lot well this has been higher the last 2 days mhmm and what worries me is is it some about with your brain you mean well I think over is it both sides of your eyes or just 1 eye the vision goes completely your vision completely goes you hear a sound your vision goes now and I could sort of feel it creeping up or sometimes but and how often will you have this how often will you have this well it's mainly just started since this first started 2 days 2 days mhmm and have you had it while you've been in with us yeah I was in it 3 times and that's an old problem is it when your heart goes into a funny rhythm sometimes you can drop your blood pressure a bit when that happens and not you solvable like solvable failure I tell you you know we can scan your head and make sure there's nothing worrying in there if you'd like I'll tell you what my wife is on to me count on my door mhmm it hit me straight in the front took me off my feet backwards jesus and dropped me on the floor when we ate at the poor thing and it was a royal clatter I don't know I avoid banging did you come to see us after no buddy mhmm since then I've my hands in my neck and I'll come comes up under the shoulder mhmm up the back of me yeah and when was this that 1 yeah when was this again that that comes in the left that does middle left comes the the smiley way I'm sitting if I was to sit on the side of bed sitting up on the side of the bed reading a book on a paper mhmm I would tell the pain before I get to show it up in the your neck and this was after you had a tumble when was when was the tumble a couple of weeks ago oh it's been about 2 or 3 months 2 or 3 months ago been like that all the time mhmm it's always good isn't it mhmm well you can have a look we can make sure there's nothing worried of course yeah that's absolutely fine and tell me about your life more generally you walk around sometimes with a stick sometimes without how far can you walk before you have to stop well not far the the length of this will be the whole length of here to there no not far at all we got we got the farm shop okay yeah okay and the walking on dilts would be the next 1 or a lot of stuff yeah stop that flight okay fine so maybe what 10 meters yeah 10 meters or yards maybe yards I don't know what's your meter sorry yeah that's fine I don't know they're roughly they're similar aren't they 10 yards 20 yards yeah something like that there's 50 of this 05:00 so that's fine and you live with your wife at home so you're talking from lynchburg yeah that's oh so a fair way so you're you're about 30 yards 30 to 3 yeah sounds good I've had you yeah and tell me about your life you live with your wife at home short yeah what did you do for a living in 2 places what did I do oh I finished in '19 yeah what did you do for a living driving what kind of things did you drive you were a chauffeur yeah mhmm bye oh it was around recently bye but what so you did like events and weddings and things it's it's something my father started me it was 1924 wow and then I took it yeah I'm quite and what did you do in the second world war how old were you there I wasn't in new york I was 9 you were having quite young wouldn't you yeah but you might have remembered it oh I yeah I remember it yeah remember the having nothing in the morning the cold food yeah I was about were you around here 32 of them we started in '38 really mhmm I would be about 60 yeah of course and what were you around here when during the war were you in devon have you always been in the midlands fine yeah right away yeah didn't have a tow back where he was no 10 miles outside of birmingham yeah fine I'm losing the green here lovely okay fine and do you drink or smoke no I used to used to smoke holiday but not foreign I drink a lot mhmm it was whisker and how about fine and how about smoking I smoked for the time mainly yeah when I was in my twenties yeah 20 a snorkeling. Maybe what a pack a day for that time a pack a day for that time oh no I've never been a real heavy smoker but that's it then I had some problem with my chest and mhmm I stopped smoking and and and knew I'm not great sorry mhmm and you were previously on some isosorbide mononitrates weren't you some nitrates but they stopped a while ago I stopped them a few weeks ago I mean weeks ago we stopped them few we stopped them a few weeks ago yeah but a week or 2 ago catherine's at the dentist and the doctor had reordered them again okay is it time for me again fine but my suspicion is oh took them since then and the aspirin every morning aspirin yes out of the doctors fine okay very good can I have a quick listen to your chest yes thank you the autoimmunity right yeah the fat cells I know that's what she was like that's good I mean you know well unfortunately it's helping my son right yeah I mean that's so you you've taken these out of this so your palpitations are on its own your lungs are you know 93 years old so they're a little bit stiff there's nothing much to worry about with them they're doing you fine at the moment your levels are fine can I look at this vein in your neck can you look over at that corner of the room for me is your vision going again yeah just felt mhmm not as intense as as it mhmm that's when your heart's in that funny rhythm mhmm you're in that funny rhythm now mhmm sometimes when the heart goes into that rhythm you just drop your blood pressure for a few moments and because you're not able to get any blood to your brain in your head you kind of go all a bit funny and then you come back around again yeah I don't I wonder that's what's happening a candle so it's right like I just stand up stop it it's spinning around yeah and that's so great reckon it is yeah when your heart's going very very fast it's not making very much blood to move over to your head sometimes it sounds like it's bumpy I bet you'll feel a palpitation certainly are you able to look over into that corner of the room for me lovely that's fine rest your head back if you can I'm just looking at this vein in the room that's fine maybe he's not raised that's good can I touch your tummy mhmm how are your bladder and bowel's doing and yeah I'm passing water I've had a swelling in the morning I've got a white coat it's very tight you know it's home I to the hospital once we get it it's not like it but do you need time to say no I think we've watched so seen the sandwiches yeah I've seen the doctor never yeah good stay away from us yeah I yeah once we got our claws in you we're terrible we didn't remove the hedge oh just before coming for me and see what I treat they mentioned the 1 wrong mhmm and she was not in there I tripped and got me shoulder and and all that was the best to go and then what man's jewish boys so they played a lot I've been I went to I beg your father yeah yeah for different things I lived in hospital think about that mhmm well sorry you have a bad aren't we okay and and in terms of you live in a bungalow is that right no you live in a bungalow still yeah fine when people come into hospital I always ask them about what they'd want if they were to get worse in hospital if your heart were to go into a funny rhythm or stop I think it would be entirely reasonable us to push on your chest a bit and try and restart your heart because there's something clearly reversible going on however some 93 year olds would say I don't want that if I go I go what's your feeling on that well everything's really rational now what the time you've had this dose of this medicine yeah you then need to go on another medicine a drip of this for about 12 hours to really cement it in to make sure your heart doesn't go into that funny rhythm now now like so you need to stay in hospital to have that drip for about 12 hours you need to go to our cardiology I'd recommend you go to our cardiology ward where we can keep a close eye on you and then see 1 of cardiology specialists there to see whether looking into the heart with another angiogram wire test might be the right thing to do like what you had before with the stent that's what I'd suggest because I think it's likely that you've had a heart attack as a cause of all of this the stents first on it mhmm I took 2 months mhmm and 2 2 it did say it made a difference they did make a difference yeah good I figured it would stop yeah and we could try and do that again we could try and do that again so what do you think if if you were to get worse in hospital and your heart were to go into a funny rhythm what would you want us to do I think offering you some treatment in that initial phase is the right thing to do because there's something clearly reversible there is that alright what would you do well if your heart were to go into a funny rhythm such that your blood pressure went very low we would push up and down in your chest to keep some heart some blood moving around your body and we could do some tinkering with the electrics with your heart with 1 of our machines to try and get it started again some people would say I wouldn't want that some people would say they definitely don't want that sorry you don't tell me that do you you need it to keep going certainly and some people would say look I'm 93 my quality of life isn't very good and so I don't want to carry on but your quality of life sounds quite good doesn't it I do a lot of things in the garden yeah great it's a limited yeah yeah it's up to you really but I think that sounds fine is that alright with you what what do you do then well we'll give you a drip of this medicine to keep the heart in a nice rhythm we'll get you over to our cardiology ward I'll ask them to think about putting a wire into your heart to look at the blood vessels in the heart and then like this yeah over the next sort of few days yeah while you're in hospital with us alright and then in the meantime if your heart goes in a very funny rhythm if we're able to correct it then we will okay okay great it was nice to meet you yeah pleasure nice to see you later plan is a miordering infusion so plan is infusion of amiodarone ccu bed with monitoring medical management of nstemi discuss with cardiology regarding the offer anticoagulation in the context of amiodarone and possible atrial fibrillation on ecg do we need to give more than fondaparinux tap for cpr if given clear reversible cause of arrhythmia however if prolonged resuscitation without arrhythmia cause then for prompt cessation given advanced age vt prophylaxis with fondaparinux