Transcription - 20260329T 11-38.mp3

Sir michael collins 1373093 initial venous blood gas ph 7.293 with lactate 0.8 and base excess positive 1.5 subsequent arterial blood gas ph 7.37 p o 2 20.8 100% saturations basic sense - 1.1 ecg atrial fibrillation at 48 beats per minute actually not atrial fibrillation first degree heart block at 48 beats per minute can you go ahead thank you thanks so investigations ct head established encephalomalacia from an old infarction in the left occipitoparietal region chronic sinusitis in the left maxillary sinus rest of the gray white matter differentiation normal ct angiography of the brain no large vessel occlusion mild arthroma of both carotid bifurcations with no evidence of flow limiting disease no intracranial aneurysm diffuse interlobular septal thickening and patchy ground glass opacities in the lung apices consistent with interstitial edema full blood count hemoglobin a 128 neutrophils 3.57 mild eosinophilia naught 0.58 chest x-ray bilateral increased opacifications to the mid zone with prominent vasculature throughout increased hazy opacification on the left compared to the right no clear pleural effusions possibly some fluid in the fissure cardiomegaly on examination heart sounds normal chest crepitations to the mid zones bilaterally peripheral edema to the knees observations heart rate 68 blood pressure a 179 over 84 saturation is 99% on oxygen end tidal co 2 4 respiratory rate 8 83 year old man so history of him with ambulance crew normally fit in mother no no medical problems currently staying with a friend to care for her she recovers for an operation and has normal self and behavior and activities next line first 24 hours no recent history of falls injury new pain friend went to wake him this morning as he wasn't awake yet found him lying in his bed she was unable to rest on 919 lying supine in bed covered with thick dailey naked from the waist dug my upper jaw bottoms responding to voice but not making any effort to talk intermittent snoring breathing gcs 7 initially hems attended as well he keeps having apnea yeah what are you what's on the plan for itu in terms of yesterday the brief apnea is noted on examination here as in the ed as well as in the evidence history ecg first through heart block with a rate of 40 they gave ondansetron and atropine on the scene but didn't clearly improve his I'm just doing the paperwork I have to go in a minute okay yeah you meet michael collins yes I am michael collins okay alright how are you I'm good the medical records are obviously call today from medicine yeah I've I've had a little read about what the paramedics said when they saw you at home yeah has he been okay recently recently yeah yeah yeah no trouble no not been complaining of any illness or anything like complaining that we went to the village post office yesterday and the day before and he was he was finding it a struggle but he was too you because mean they switched his chest right and he's short of breath that's right and he was having pain in he his was breath shoulder short around and his legs were saying you which is unlikely to have 2 to a run through no he he does take tablets for joints okay glucose I mean I think it was okay yeah I had just had a mastectomy alright so he's been looking after me okay then he went back to the isle of wight for 10 days to meet his sons mhmm 2 of them live on the island 1 in cambridge and 1 in southampton and 2 of them are just on their way here one's just got on a ferry and the other one's driving like a madman from southampton very worried obviously he's 3 of them married and he's just got back on thursday because he's had 10 days on the island but that's been great and he's been fine I mean we've popped into yish and abbott and bought shoes and was it little short of breath then no no mhmm no and we had dinner last night and the cats were there because we have 3 cats yeah he always gets up to feed the cats and sort things out but this morning I got up and we have a healthy lifestyle and we have water and lemon in the morning okay no and he's very fit and well I take it well you can independent he looks very fit there's no me probably he's very fit we're both very fit mhmm and he does everything for himself yeah does he do much exercise no he doesn't do any exercise but he walks lots of places in fact he had to go to southampton to see his son he walked down to the ferry okay and coming up he said he found it quite difficult mhmm I think maybe the heart I don't know maybe mhmm so that's his lifestyle mhmm would if we do we talked about his garden in cows fine so you were gardening together that's hard I didn't go ground okay I didn't go because I've got cats cats at home fine and I wasn't I haven't really been well I'm only just stopping of course get get back to normal completely understand and I've started to do weeding and stuff he we go I mean I go over to watch the sailing in august and what have you and we go on holiday okay when did you last go on holiday oh great were we canceled in april we were supposed to bring him to costa rica mhmm but unfortunately with his of course vasectomy which was on the february 10 it was as it was it's quite a oh a lot holiday so of course but normally this morning that's why I was healthy you know it was the evening this morning I couldn't wake him up yeah and the boys were sitting on the bed looking at you what's he doing the boys the cats the cats I see no that's fine I know you've got it's a bit of levity into serious situation haven't you yeah of course yeah I am not next of kin mhmm I have been here before with my second husband I heard about that so I don't really want to get involved too so yeah he's been fine mhmm it's just this morning I couldn't wake him and I'm going like that mhmm he's gonna I won't open his eyes yeah and since he's come in he's had a few tests yeah he's had some blood tests the first few sets of blood tests have come back there's nothing clearly abnormal there he's had 2 scans of his head 1 has shown an old stroke which you may or may not have ever known he had it's very old really weeks to years old yeah you know somewhere between 2 years about 9 years you see I see right so far yeah so it's it's probably a very old stroke you may not have even realized he ever had it sometimes you can have small strokes on him that yeah and he's had a scan of his head looking for any occluded vessels and he's not got any of those no so it's a bit unclear at me straight at what's going on certainly looking at him seems that he's got a lot of fluid on his chest I agree probably because of because of his heart not working fantastic he's got a bit of fluid in his legs yeah but whether that's prime the primary thing or whether that's something in the background is difficult it wouldn't usually cause people to be so sleepy and struggle with their breathing he was struggling with placebo yeah so I've we're waiting a few more tests yeah do it yeah I was going to speak to my colleagues in intensive care yeah because I think when people struggle to breathe sometimes they need to get support to have them breathe okay and I just wanted to make sure you felt that would be the right person to hear and then you would want that well I I I know this hospital so well obviously of course and I know yeah it's very good yeah yeah the the carry on I think boys when they arrive here stuart will be quite a long time because I know he's got on the ferry of course it takes a while to get him sometimes yeah of course yeah but jeff should be here within about half an hour mhmm so perhaps you will come speak to him yeah that's fine shall I tell the lady next time if he comes of course yeah when when I guess he can come in to see he can't be yeah welcome to I'll be there and there all the time looking after I'm I'm not good at going in there that's okay right very interesting don't mind it's fine and I have been in there yeah okay it's okay so so we don't know mystery we don't know but we're waiting for tests but there's no history so he's safe at the moment he's in the right place yeah and he'll wake up yeah I'm sorry I so I hope so yeah or you just know do you we don't yeah 83 or so it's a bit it's a bit strange and yeah we'll see we'll see what our tests come back as and we'll we'll see 's what going on yeah but I think we'll we'll see to the next question no no no if you if you ever want to see a moment there yeah I'm glad you're here you're I'm glad you're here I'm I'm I'm glad here glad you're here I'm glad glad here collins hi hello hi mister collins michael hi michael I'm rob 1 of the doctors can you open your eyes open your eyes mister collins open your eyes okay so eyes open can you tell me where you are at the moment where are we early we did say torbjorn hospital can you squeeze my hand can you poke out your tongue can you keep your hand held up like this 4 from 5 l 6 l down to 1 l of oxygen because he stands for a 100% and his apnea seems to have improved

Presenting Complaint:
Reduced consciousness

History of Presenting Complaint:
83-year-old man found unresponsive in bed this morning by his partner, who had difficulty waking him. He was lying supine, covered with thick bedding, and was responding to voice but not speaking, with intermittent snoring respirations and apnoeic episodes. GCS was 7 initially, with brief apnoea noted in ED and by ambulance. HEMS attended and administered ondansetron and atropine without clear improvement.

Collateral history from partner: he was normally fit and well, independent, and had no known medical problems. He had recently been staying with a friend while she recovered from mastectomy. Over the preceding 1 to 2 months he had been more short of breath, with reduced exercise tolerance. There was no history of falls, injury, or new pain. He had been on the Isle of Wight for 10 days visiting his sons and returned on Thursday. He had otherwise been well until this morning.

Past Medical History:
• Old left occipitoparietal infarction with encephalomalacia (identified this admission) - coded as TIA
• Chronic sinusitis

Drug History:
No regular medications

Allergy History:
NKDA

Social History:
Lives with partnertemporarily. Independent and normally fit and well. No regular exercise, but walks to places. Recently stayed on the Isle of Wight for 10 days visiting family. Former or current smoking and alcohol history not mentioned.

On Examination:
Drowsy with intermittent apnoea and snoring respirations initially.
Observations: HR 68 bpm, BP 179/84 mmHg, SpO2 99% on oxygen, RR 8/min, ETCO2 4
• Cardiovascular: Heart sounds normal. Peripheral oedema to the knees.
• Respiratory: Bilateral mid-zone crepitations.
• Other: Cardiomegaly on chest X-ray.

Investigations:
• Venous blood gas: pH 7.293, lactate 0.8, base excess +1.5
• Arterial blood gas: pH 7.37, pO2 20.8, saturations 100%, base excess -1.1
• ECG: Initially reported as atrial fibrillation at 48 bpm, corrected to first-degree heart block at 48 bpm
• CT head: Established encephalomalacia from old infarction in the left occipitoparietal region; chronic sinusitis in the left maxillary sinus; otherwise grey-white differentiation normal
• CT angiography brain: No large vessel occlusion, no intracranial aneurysm, mild atheroma at both carotid bifurcations without flow-limiting disease; diffuse interlobular septal thickening and patchy ground-glass opacities in the lung apices consistent with interstitial oedema
• FBC: Hb 128, neutrophils 3.57, mild eosinophilia 0.58
• Chest X-ray: Bilateral increased mid-zone opacification with prominent vasculature and increased hazy opacification on the left compared with the right; no clear pleural effusions, possible fluid in the fissure; cardiomegaly

Impression:
Reduced conscious level with intermittent apnoea, likely in the context of pulmonary oedema/possible cardiac failure. Old left occipitoparietal infarct on imaging. First-degree heart block with bradycardia.

Summary

Investigations

Plans