Transcription - 20260329T 16-52.mp3

Barbara hines 1143177 82 year old lady lives in a nursing home suddenly onset of unwell vomiting shortness of breath past medical history lives in a nursing home medications list brutemide 40 mg bd metformin 500 mg once a day laxido once a day paracetamol is required clonazepam 5 1 mg so that's 1000 micrograms at night fluoxetine 20 mg twice a day aripiprazole 15 mg once a day senna 15 mg at night when required lanzoprazole 30 mg in the morning giveothyroxine 100 micrograms in the morning past medical history severe frailty coded april 2025 accrual to clinical frailty sore 7 ulcers 2023 gallstones 2022 knee osteoarthritis 2021 type 2 diabetes mellitus 2021 ckd 3 b hypertension hypothyroidism schizophrenia previous stroke with left sided weakness rival of the ambulance cruciate was pyrexic at 40 tachy a 125 respiratory 28 blood pressure 170 over 90 and hypoxic on air 77% investigations blood cultures negative so far chest x-ray pulmonary plethora no major collapse of consolidation identified coagulation screen normal creatinine 117 for a baseline of 94 sodium 131 from a 134 potassium normal crp 27 from 11 urea normal full blood count hemoglobin a 121 neutrophils 8.53 from 3.17 and total white cell count 10.1 from 5.4 normal venous gas ph 7.42 sodium 130 basic assessment naught 0.3 his recent h p 1 c 03/13/2026 57 millimoles per mole previous microbiology of leg ulcers growing staphylococci aureus susceptible to clarithromycin doxycycline flucloxacillin but resistant to penicillin urine cultures from october 2025 negative no positive previous microbiology to the plan absolutely impression is of hospital acquired pneumonia + or - viral infection to exclude urine infection and aki on ckd plan iv fluids iv antibiotics quad swab urine mcns add tsh to bloods benzofuruzomide while treated for infection the spindle lansoprazole or hyponatremic if hyponatremia worsens despite fluid check urine osmolality urine sodium and review fluid status daily bloods while in u and e but that 1 in aki if aki worsening consider renal ultrasound k how are feeling it's fine how's your chest feeling any pain again are you still feeling short of breath no good night I'm rob I'm 1 of the medical registrars I briefly saw you in a and e yeah I just came down and quickly listened to your chest is that okay mhmm have you had any more vomiting since you came into hospital no that's good I'm looking at the blood side that's good good good good good good good your tummy your catheter's coming I'm sorry we put this catheter in new did we did we put this catheter in new when did you last goop for a poo when did you last goop for a poo how long has it been do you think a lot of times blood flow not your tummy is quite distended and quite tympanic when I tap it it's full of gas and you were vomiting when did you last go for a pee in there about a week and your leg looks a little bit red hey your right leg look at erythematous and it's certainly very warm to touch and you've had ulcers there before haven't you yeah you wanna express the other 1 is that painful yeah chlamydia sorry just do that oh so edema to the mid calf but your left leg certainly is a little bit I'm just not gonna throw that a hole yeah you can be how will you go for a wee how are you weeing in the nursing home terrible you're on top you're earish hey I think you got an infection on your leg we should give you some antibiotics to treat that oh the cellulitis I think that's made you poorly and your kidneys have taken a bit of a hit with that and you become quite dehydrated and that's led to you becoming quite constipated and that's caused the the vomiting and the and the pain it'll be nice to know what's coming out of you and measuring the fluid that comes out so from my perspective selfishly keeping the catheter would be good sorry I've just got yogurt on myself but if it's hurting you then that's fine we can stop it thank you you want to you want to have it out yeah that's fine so we'll take your catheter out I'll I'll send you a swab just to make sure you've got any viral infection we'll treat you for cellulitis we'll get an x-ray of your tummy to make sure that there's nothing clearly obstructed there then we'll get you some laxatives to help you move things through are you doing that that's okay I appreciate that the chest is nice and clear could have her tummy what can I call it extension and look at your tummy if you're right certainly distended and warm to touch and keep that up alright can I see your tongue thank you a bit dry that's fine thank you we'll get you some fluids if you feel any better we're gonna get you over to our acute medical unit where I always have to too much that's all it too much no too many covers yeah you're too hot no is that better yeah can get your feet out is that okay yeah sorry I didn't know you wanted your feet out I'm just trying to make you look beautiful more beautiful okay so nice to meet you are late are you allergic to anything no good now I'm not going to get any more fluently you like I'm take you on a bike don't you if that's okay she's quite a few tights on you you can tight while she's in gray can't you yeah I just won't take her oh thank you I really appreciate appreciate it how many people at the moment I've already written those off here okay I'll just write that down really yeah

Presenting Complaint:
Vomiting, shortness of breath.

History of Presenting Complaint:
82-year-old lady from a nursing home with sudden onset unwellness, vomiting and shortness of breath. On review, she had not had any further vomiting since admission and denied chest pain or ongoing shortness of breath. History from the nursing home and initial assessment suggested dehydration and infection. She was noted to have marked abdominal distension with tympany and constipation, with last bowel motion about a week ago. Urine output had been poor in the nursing home.

Past Medical History:
• Severe frailty, CFS 7
• Pressure ulcers, 2023
• Gallstones, 2022
• Knee osteoarthritis, 2021
• Type 2 diabetes mellitus, 2021
• CKD stage 3b
• Hypertension
• Hypothyroidism
• Schizophrenia
• Previous stroke with left-sided weakness

• Diabetes mellitus - latest HbA1c: 57 mmol/mol (13/03/2026)

Drug History:
• Furosemide 40mg PO BD
• Metformin 500mg PO OD
• Laxido PO OD
• Paracetamol PO PRN
• Clonazepam 1mg PO nocte
• Fluoxetine 20mg PO BD
• Aripiprazole 15mg PO OD
• Senna 15mg PO nocte PRN
• Lansoprazole 30mg PO OD
• Levothyroxine 100 micrograms PO OD

Allergy History:
• NKDA

Social History:
Lives in a nursing home.

On Examination:
Unwell on presentation. Febrile and hypoxic on air.
Observations:: HR 125, BP 170/90, Temp 40°C, RR 28, O2 sats 77% on air.
• Abdomen: Markedly distended and tympanic with reduced bowel motion suspected; no clear obstruction on initial assessment.
• Respiratory: Chest clear on auscultation.
• Other: Right leg erythematous, warm and swollen to mid-calf with previous ulcers noted. Mucous membranes dry. Catheter in situ initially, later removed on request.

Investigations:
• Blood cultures: Negative so far
• Chest X-ray: Pulmonary plethora; no major collapse or consolidation identified
• Coagulation screen: Normal
• Creatinine: 117 (baseline 94)
• Sodium: 131 (baseline 134)
• Potassium: Normal
• CRP: 27 (previously 11)
• Urea: Normal
• Hb: 121
• Neutrophils: 8.53 (previously 3.17)
• WCC: 10.1 (previously 5.4)
• Venous gas pH: 7.42
• Venous gas sodium: 130
• Capillary blood glucose: 0.3
• Previous microbiology of leg ulcers: Staphylococcus aureus, susceptible to clarithromycin, doxycycline and flucloxacillin, resistant to penicillin
• Urine culture (October 2025): Negative
• HbA1c (13/03/2026): 57 mmol/mol

Impression:
Hospital-acquired pneumonia versus viral infection, with concurrent right leg cellulitis, dehydration, constipation and acute kidney injury on CKD. Urinary tract infection to be excluded.

Management Plan:
1. IV fluids.
2. IV antibiotics.
3. Quad swab and urine MC&S.
4. Add TSH to blood tests.
5. Hold furosemide and lansoprazole while treated for infection.
6. If hyponatraemia worsens despite fluids, check urine osmolality, urine sodium and review fluid status daily.
7. Daily U&Es while in AKI.
8. If AKI worsens, consider renal ultrasound.
9. Abdominal X-ray to assess for obstruction.
10. Start laxatives to relieve constipation.
11. Catheter removed.
12. Transfer to acute medical unit.

Summary

Investigations

Plans