Nate brett b r e t t 1313592 45 year old man medications list abstrel 100 microgram sublingual tablets as per retroph hospice paracetamol as required docusate 100 mg twice a day selen 7.5 mg to 50 mg at night thomoxetine 40 mg once per day macrogalts 2 saturdays each day past medical history temporal lobe ep epilepsy 1991 depression so underwent coloscopy 2022 showed large sigmoid polyp underwent laparoscopic assisted left hemicolectomy 20 22 may jukes c 1 nodes positive and apical node negative t p t 3 p n 1 a p m x cancer ct 15 months later demonstration of recurrent disease and pet were in keeping with tumor recurrence uptake related to the left humeral head underwent adjuvant zellox and tomox chemotherapy and then attended bathing state for excision of abdominal wall mass peritoneum omentectomy left hemicelectomy excision of para aortic nodule and left nephrectomy in july 2024 january 2025 resumed his immunotherapy unfortunately evidence of progressive metastatic disease and felt for best supportive care most recently presented january 2026 multifocal strictures from duodenum small bowel to distal ileum serious obstruction from periaortic disease involves a small bowel antral involvement and narrowing other focal disease difficult to define on rereview of scan with the basic stroke team moving to doctor johnston from nutrition and having total parenteral nutrition with ryles tube in situ for venting symptoms managed with evening it's gonna be peg tube and community parenteral nutrition via picc line so a call from the palliative consultant doctor human today that he's suffering with cellulitis temperature 37.7 at home he uses 2 syringe pumps 1 with clonidine which he uses for analgesia and 1 a conventional with just in case medications worsening lymphedema in his left leg particularly has been trying furosemide 40 mg bd via his ryle's tube they feel his prognosis is short weeks they also think that he's at high risk for a dvt I spoke to your palliative consultant doctor heumann earlier yeah and I know all about what's been going on I've been I work with doctor johnston quite a while already oh okay so I've read the letters and things like that so I understand what's been going on I'm sorry to hear that you think you might have a of cellulitis is that right yeah that's right pretty sure possible cellulitis yeah so the last couple of no the last 3 4 days I've had really bad knee pain mhmm almost like I've had like a knee injury last couple of days that's become there after the time I go to sleep mhmm yeah so and then I got this red heat patch thing here on the inside yeah yeah yeah yesterday mhmm and I did get prescribed prescribed antibiotics it was oral antibiotics yeah I just don't it's gonna be very challenging with wild tumors difficult but also I just it was so much of it and I found it really like and so when it came to getting get into the evening bags I couldn't face it and so doses did you have in total I had 1 and this is flucloxacillin 4 times a day mhmm this is quite an email once yeah well it it was 4 or 5 mil yeah and not even a full 1 1 dose is that yeah so it was yeah it was 1 1 dose good I'm also on water tablets yeah there's some freezing of it to try and get stuff up here they're they're solid very challenging down there so you crush them up mix them with water and chuck them down the rales now I just swallow them swallow them and spigot your rales yeah spigot their rales yeah but I just don't think they're really doing much with your diet if I could also I mean I'm not gonna no no no please I'm happy if I could have them iv as well that's fine obviously the swelling that you've in your leg it's unclear how much of that is because of fluid retention because of blocked lymphatic drainage because of what's going on in your pelvis so it's worth trying certainly and we don't actually have that many other tools in our arsenal to fix that so frutamycin I'm trying the intravenous the amount that was prescribed yesterday the was based on the fact that I wouldn't have a regular absorption so I assume it'll be slightly less yeah we just need to do the nor a normal dose yeah good of intravenous fluoxetine just 1 yeah we'll do that and we'll get you the same dose of furosemide that you have orally which is 40 mg is it so I think that's I think that's probably doubled so I think you wanted to start on 20 orally did you don't mind if you think that 40 like intravenously would be no so 40 intravenously would be the equivalent of 80 orally so it's twice as potent intravenously yeah yeah yeah the equivalent of an oral dose of 40 would be an intravenous dose of 20 that sounds okay yeah but if you've doubled it because it's not being absorbed yeah that was the idea I think yeah fine so so you so you started off on 20 nothing really happened you stepped up to 40 yeah nothing really happened yeah fine we'll we'll give you 20 mean it's hard to draw up less than 20 to be long yeah that's exactly how you're and we'll see what happens yeah and in terms of your line how's that you've you've got a long line haven't you yes so it's been flowing reasonably well sorry not your ryall's tube you've got a picc line oh my picc line okay how's it looking yeah it doesn't look infected or anything like that at the site I'm gonna have a quick look do you mind if we do thank you yeah yeah just because I guess in the back of my mind your crp is 200 so certainly some evidence of infection and it probably is cellulitis but in the back of one's mind 1 has to just make sure that the line is good because if we're going to use the line it may be safer to use a peripheral cannula while we wait for the cultures to come back because the problem doesn't have to go tender at all pressing down the needle and that works very helpful I can show you the cellulitis and tell me about the tpn situation are you using that at the moment yeah yeah I just use it every day that's fine you use that do you feed over lunch yeah 12 hours and do you have custom made bags or yeah yeah fine and where do get the bags from here so we've got them at home get them delivered I've got them in a medical credit report I can bring them in and do that if we're gonna feed you then we unfortunately can't we can't make up a cashew with us so if we're gonna feed you we should have them however on the back of my mind I just wanna make sure that line's not infected so I wonder whether leaving you off the fever tonight I know it's a bit of a bit annoying maybe sick okay to make sure that the line's not infected if the cultures will come back tomorrow and if they're clear then we then we can restart it but just safer because if you've got a little infection typically lining of the knees then we just chuck it everywhere yeah great sorry so that's just saying how it is yeah it is much warmer than the other side is very tender when I press it it feels a bit bruised a bit bruised mhmm I'm pushing back here on the tender yeah so that's fine can you extend your leg a little bit behind you yeah how's that that sore back to no that's really just wondering about dvt as well I'll just stop the patient on that 1 more day than what it obviously normally do yeah yeah my lungs are and scanning that while you're in to make sure you have a concomitant dvt which sometimes happens with cellulitis think a dvt a deep vein thrombosis oh okay a clot in 1 of the deep veins in the lung oh okay because that can cause it to become a hot and red painful just as much as cellulitis certainly the markers of infection are up so I'll treat you for an infection but in the back of my mind it's been good to just make when I did take the antibiotics antibiotics yesterday and I know it's a bit could be chance yeah that my knee pain did go down oh good yeah you can have both at the same time as well so yeah yeah worth making sure can I help you with this 1 is there anything else to look up so I don't know how ready it's down below red down here yeah the nurse didn't re bandage him over the load basically okay very good you're you're very much dressed aren't you I think I've had very comfy trousers oh really yeah look good can I have a proper look is that alright yeah yeah yeah these ulcers here under the ear or leg they've been leaking been leaking yeah they've all been leaking physically of course in the I'm have a chat it's a bit moist isn't it yeah a little bit redder and fatter so that's good okay send a if you any fluid comes out of your upper leg we can send it culture it and find out where is from it just let us know if it starts leaking up there but it doesn't look like it looks quite dry at the main yeah yeah yeah but I wouldn't bother sending that off it's just gonna grow normal skin stuff it's not the skin isn't infecting around it that sound okay have a listen to your problem back but I also haven't put your hands off if if if it's a helpful thing for you to do that's alright what's going on it's alright it's just you've had to get a little of your mind and you've got 2 sutures like I or it 1 with the clavudine yeah 1 with what oh 3 d the oxy but it's something else as well mhmm no bring it in when I get if you get the tpn that would be amazing yeah thank you how many I think it's unlikely we use the tpn tonight yeah because we're we're gonna alter because I've been assuming you've got enough in there well that'll last until tomorrow because so you're not gonna talk we could sort all this out tomorrow morning if you want yeah we could bring in more pumps and a tpn tomorrow hopefully then could have a plan about when we're gonna feed you and seeing you in these syringe drivers also know what's in there often they're right on with syringes so are we gonna start the antibiotics tonight is that alright yeah yeah I think it's gonna be about 24 hours to be in the hospital is that okay yeah that's fine think antibiotics now I was against coming in hospital until I like realized how hard it was gonna be to be at home so I prefer to be here and get sorted out good we're happy to look after so I'm not I'm not worried about being he's not desperate to leave he'd rather be on new pill before he went out yeah we want that as well yeah yeah so we're gonna make sure your line's not infected start you on some good strong antibiotics watch your inflammatory markers come down once the line's not infected we'll switch over to using the line and restart your tpn if that all happens you're feeling better then we could get you on some intravenous antibiotics continue it would be the optimal thing to do and I'd hope to get that sorted for first 24 hours brilliant did you try to listen to my if that's okay yeah okay I'll let you do that for me thank you okay I had a big breath that's alright thank you alright look in I've been having some chest pain but I think it's I think it's really a trapped wing to the other girls I've had some burps and it's then made it feel weird all night okay alright and is that gas coming up the rales or you're just burping it up sometimes do you have any problem with the rales coming out or I haven't done no well I have had it come out once but it's been yeah I'm sort of fairly on top of it yeah good yeah so obviously you could get stuff building up if it was not the exact right place yeah oh yeah I know yeah yeah and the thing is I I can self administer a fairly dark night like me I was in changing my change the ring or change the back I don't change the position mean I don't you're not pre inserving no I don't I'm not allowed to kiss me what I was going to ask is we got tpn nurses so will I stand on the tpn nurse for tonight are you community nurses yeah community nurses yeah they've got bad start yes mhmm and then are you guys gonna take over tomorrow morning yeah so the so tpn is poorly done by the amu nurses because they're so you're gonna have your tpn tomorrow you need to be up on that and out of 10 yeah to have that done that's a very quick that's review helpful completely yeah but he's rang and requested that I get moved up there brilliant fine I've asked you to go 1 floor up which is a bed space which is nice and neat oh really happy to come in room yeah yeah and then well you can have your tpn because otherwise yeah we don't really do it where the nurses come into hospital and go to yeah like 1 1 space up for a bed square well they won't be able to use the actual bed as long as it's got a chair I've got a fracture in my spine from the I've got to have my legs down basically mhmm mhmm I'd I'd bring them up to give them elevation for the drainage yeah but I've got to them bring back down fairly short negative culture and get you feeling for having your your tpo which I guess will be optimal for you speak to they will be they will need to speak to optimal I've got room questions for you no it's all good to anything fibrofur which is a yep connection that's fine but I won't give you any so no like sooner we can start the antibiotics right sure thing is that gonna be okay yeah well they'll get there eventually yeah okay great okay yeah thank you bye bye bye bye bye