Next patient is norman sharam 516 okay 578 93 year old gentleman if they're normal you just tell me they're normal but if there's something I want to know are they okay hemoglobin 121 but chronically anemic since october 2025 platelets 516 but normal back in may neutrophils 12.29 and white cells 14.2 can I have her nhs number I'll just look at creatinine 108 which is our patient's baseline electrolytes normal lft is normal crp 39 previously 14 in november 2025 urea 5.8 ast normal what other medical problems venous blood gas ph 7.23 with a lactate of 2.8 and a base excess of - 2.6 have you noticed any lymph nodes no recent investigations for myeloma which was did not detect any paraprotein in november 2025 but appears to be anemic in a pattern of iron deficiency folate and b 12 normal in october and ferritin 222 in november 2025 so more like an anemia of chronic disease with a viral sort of picture you would have ex you know you know you would think after a week it would go back it's a chest x-ray the most bilateral lower zone opacifications with increased bronchovascular markings to the mid zones but with dense opacification and effusion on the left with hazy opacification on the right mid zone fluid in the fissure blood culture is negative so far tep form undertaken by the ed team but for lack of treatment if required but not for it or cpr yes so ecg rate a 110 atrial fibrillation with a rapid ventricular response medications torvastatin 20 mg a day glipidogrel 75 mg once a day dermal lotion finasteride 5 mg once a day tamsulosin modified release 400 micrograms once per day past medical history ckd 3 stroke 20 21 diverticular disease 2012 osteoarthritis good view good let's do it that's it good brother very good hi mister sharon I'm rob hi I'm 1 of the medical registrars nice to meet you you live missus sharon yes hello I'm rob nice to meet you how are you I'm not very well I can tell I have noticed yeah breathing is it a problem mhmm the breathing's been the problem has that been a problem for a while now or is it just today so it's it's been almost a day now almost a day now yeah mhmm are feeling suddenly short of breath well it it came suddenly mhmm and I thought it was a panic attack oh goodness it wasn't I was just at harper's 3 this morning and I couldn't breathe and it was and a panic you were laying in bed I take it as most people are at 03:00 in the morning yeah you were asleep I was you were and what woke you the feeling of shortness of breath very good do you sleep flat no do you sleep flat no or do you prop yourself up on lots of pillows no 2 pillows like whatever everyone's high altitude pillows normal yeah so you sleep flat on 2 pillows then you suddenly woke up at 03:00 in the morning half past 3 feeling very short of breath yes and did you have any pain in your chest at that time no at all no I haven't got the pain it's a bit of a snowy good alright and so you woke up you sat upright did sitting upright make it better or not really not really k not and then what happened after that well because we weren't sure what it was I tried to guess we could do some slow breathing yeah and deeper breathing but he'd be a little bit more comfortable he couldn't at all and after about an hour I suppose when it didn't go away I rang 1 on 1 mhmm and they came no they they they sent an ambulance for you yeah they came and said there's been an ambulance very good it was a sudden but when we were back we had been the last couple of nights only a night she had been coughing her leg and bed also when we went for just a quarter of hour's 20 minute walk which normally we can manage we had to stop about 4 or 5 times to and get in that's not normal for you no no so how far could you walk before this whole thing happened I walked back like 20 30 fine no trouble yeah yeah fine don't worry okay but then since then over the last few weeks is that fair to say no less than that no no it's just the last few days just the last few days you're much you're much less able to walk yeah okay alright alright and I read about your medical problems in the past I understand you've a stroke before yep you understand you've a small stroke before is that right that's what your gp tells me I I did a ago yes and you take a few medicines I take them off well what not they're irritating aren't they yeah what are they they're little ecg stickers oh so we can just monitor your heart uh-huh and what happened was it was the year that the covid vaccine came in mhmm and a week after having the very first covid vaccine we had a small stroke yeah right okay but it recovers good and you're back I've had nothing like that since good yeah you take a few medicines but other than that you seem pretty well yeah is that fair to say and tell me about your life more generally what kind of things do you do well was so thankful that at that age I was mobile I would just go for walks so you can walk for 25 minutes do you use anything to help you walk he used a stick now but only outdoors indoors I didn't need a stick wonderful he only used a stick for about the last 3 months well loads and bad yeah and not slowly but mhmm I don't know he's very anxious and you know we go out and he's happy to great did you get out every day most days no yeah that's whenever age yeah which it has been recently anyways I won't let it yeah wonderful and you live in a house or a flat or a bungalow a house upstairs it looks like and you miss the stairs down the stairs I couldn't that's right pump now of course not but I did usually very good that's fine and what's your understanding of what has happened since you've come into hospital the tests we've done has anyone explained it to you or anything like that well not all that but no excellent it's I hope the word pneumonia is good and the gestation possibly flow yeah and they were in the heart yeah exactly so you've had a few tests you've come in and had a tracing of your heart which shows it's slightly irregular in what we call atrial fibrillation sometimes when the heart beats in that funny way doesn't move blood very well and blood can back up onto the lungs so that's a possibility you've had an x-ray of your chest which shows that there's some evidence of infection or some fluid difficult to tell us which 1 on the x-ray on both sides of your chest your markers from the blood show raised markers of infection and a slight anemia but you've been anemic now for about 6 months that's probably not causing any problems no but it but it all sort of contributes to the feeling of shortness of breath that you're having so I suspect this is probably 2 things I suspect you've got that slight chest infection has put your heart into this funny rhythm this atrial fibrillation and when you go into the atrial fibrillation you can't move blood very well and that's made fluid collect on your lungs which has made you you feel acutely short of breath so probably for the last few days you've been brewing a chest infection but then that's throwing everything off I suspect so 1 200 mg so you've already had some antibiotics which is great you could do with a bit of medicine to get some fluid off your chest I'd to have a listen to it and make sure that's what we think is going on from the look of your tests that's what I think we should do get some medicine called furosemide to get the fluid off your chest and get your breathing feeling better carry on those good strong antibiotics get you to our acute medical unit where we can keep looking after you you're needing quite a bit of oxygen at the moment and so we just try and get that down as much as possible and in the moment you can get off the oxygen we can get you out of hospital but that might be a good few days I would think because you're on a good bit and your body needs time to heal yeah okay that sound alright it's his birthday on sunday oh is it like to of course '94 yes how exciting have you got a big party planned no but our son is coming down nothing well I will hope to try and get you out for that but I worry that we might not no it doesn't matter it doesn't matter what capacity would you get to us you'll have more people at your birthday party if you have it in hospital can I quickly wash my hands and examine you if that is that alright we're back in 1 moment 5 5 very good that's it yeah in terms of your life more generally do you drink or smoke no no did you smoke in the past no yes yes he's he's he's smoked he hadn't smoked for 30 years 30 years right and how long did you smoke for 30 years 30 years a pack a day for that time no no not a pack a day no we used to smoke cigarettes for about 10 years and then he went over to little cigars and so he'd smoke when he was working I didn't didn't hurt you yeah ever oh ever no fine okay so it was all for effect all just for show yeah yeah well helped me meet your lovely wife I'm sure you look very cool I'll take listen to your heart are you able to sit for me I might have a listen to your back yeah can you have a hand if you need oh very good big breath whenever you're ready take a deep breath no you can okay we have definitely got a bit of a collection of fluid at this base certainly sounds like no air's getting through there mhmm that can happen in the context of infection on how this left hand are your legs doing a little bit of fluid there I hope it's not sore I'm fine good and this catheter is not us you've had that catheter a while now understand because of the prostate is that right since what '23 yeah yeah yes right and can I touch your tummy do you mind yeah any pain in the tummy at all you don't have to take anything off all okay in there seems nice and soft lovely bladder and bowels okay what bladder and bowels doing okay no no pain passing water and you went for a pre recently no good can I come back with my ultrasound machine and just scan your heart is that okay I'll be back in 1 second that's my job it's the lovely part of my job and I get time to be thorough yeah I've never seen any as empties when I walk in really the waiting room or the waiting room often empties out by the morning yes and then it'll fill up during the day yeah course everyone who can go home I think would choose to at 03:00 in the morning don't worry you're in a good place being looked after it'll all sort out in a few days change my probe oh dear that's how I did very good stop you have to be a technical bruce you've got a little old doctor bruce yeah lots of technology isn't there that's better yeah can I have a look at your chest is that okay yeah feeling little bit too good sorry it's a bit cold you said yourself is gonna come in come to see you yeah on your birthday what is he far away I haven't found anything else yeah he's coming tomorrow tomorrow lovely that's back in there k give that a bit longer can get it out of the way so some lovely views of your heart here yeah look at your heart this is your mitral valve beating away very nicely yeah through your heart sideways really beautiful seems to be working perfectly but obviously isn't no it's not there's a bit too much fluid I'd like to see these walls touching each other with the squeezing motion there's so a bit too much in there when there's too much it can't move very well this is the aortic valve here yeah moving the blood out of the heart yes what would the fluid be infection fluid no it's just too much blood oh because you when your pressure goes when your pressures come down from your heart you can't get rid of the fluid very well through your kidneys okay and then you can develop an overload of fluid and it means the heart can't eat very well and it's particularly not able to beat well when it's in this funny rhythm let's cut down here have a look at it from this angle good morning julie it's fascinating the way it works though isn't it pretty amazing isn't it there's been a yeah from the bad pictures that we used to get we're very lucky to have good ultrasound machines so we can get nice views what are you actually looking for I'm just getting an impression of how the heart's moving we're seeing the mitral valve again and the aortic valve the aortic valve looks quite stiff yeah yeah can have a look at the doppler and get a nice sound from it why would he have pneumonia well any chest anywhere to catch anything no any chest infection can cause it why would he have a chest infection guess because it's winter and you pick these things up unfortunately I guess your aortic valve's a little stiff but would come for all of us at your age sure really contributes to things certainly not bad all things considered it's been going on for 94 years exactly mine is 3 days yes mine is 3 days the last bit of the test is a little uncomfortable I'll just push on your tummy to have a look at the back of the heart so it's little a bit uncomfortable so it's good so just try and relax your tummy as best as you can 1 cough difficult when your breathing is bad is it yeah it's a it's a big throat but it's it's a there's loads of interactive stuff my honest ears 7 like I mean he I know he's 4 and he's so my son is gonna be so he's sick and stuff and how much is it though are you doing he powered so at the top here you see the fluid that I was talking about yes in your chest surrounding your heart where the lungs should be yeah I recognize it don I'll never get rid of it it's some medicine which will help you weed out you've got a good size of lung tissue I can see here is all squished together and non aerated good because of the the pressure of the fluid so do I need to bleed is that me can you just pop this at this spot yeah sorry I'm gonna it and the fluid just in the base of this other lung as well so just the tissue I don't know if it hurt you I mean in pain pain on on this this tummy tummy right I apologize you sure it's not sore is it no good soldier is not bothering you so what what do you do now well I don't think it changes what we need to do I think we should have some medicine to get the fluid off with a a drip of some medicine initially to help you wean all of that fluid out you'll produce lots and lots of urine urine in your bag that's quite concentrated like you haven't had much fluid come through your kidneys so you can wash them through a bit and help you mobilize this fluid from your chest treat you for an infection in your chest and get you up to our respiratory ward where we can look after you in bit more detail there's the potential for an infected collection within the chest here sometimes we can get pus in that area it doesn't look like that to me it looks simple which is obviously good which is why I was doing it to see whether it's infected I will prescribe it to you and the nurse I'll look after you all day and then when you come to my acute medical unit I'll keep you from looking they'll bring will they yes we'll do everything okay you see you so on examination so on examination heart sounds fast but no clearly audible murmurs silent left base to mid zone with percussion notes dony dull to the left mid zone right base also dull to percussion but with scattered coarse crepitations mild pitting peripheral edema to the knees bilaterally bedside ultrasonography echocardiography globally hypokinetic overloaded appearing left ventricle epss high aortic valve disease mixed no clear evidence of heart strain right heart strain I should say lung ultrasonography simple left sided effusion to the mid zone on the right small volume effusion b lines throughout both mid zones but apcs a lines seen so impression an ecg reviewed sinus rhythm with pvcs pulse is regular to palpate with occasional pvc seen on monitor no clear ischemia on ec 12 lead ecg impression right community acquired pneumonia with or community acquired pneumonia with parapneumonic effusion and element of congestive cardiac failure possible missed mi leading to overload however physiological stress from infection leading to overload seems more likely no current evidence of atrial fibrillation plan iv antibiotics furosemide acute medical unit vt prophylaxis pharmacologically can step down from recess wean oxygen as able observations heart rate 104 blood pressure 151 over a 100 saturation a 100% on 4 l and respiratory 35 at the examination wheeze audible from the end of the bed and throughout both lung fields most likely cardiac wheeze