Transcription - 20250404T 03-49.mp3

I was like it'll stop like me again then they phoned me on wednesday saying I'd be dismissed from the virtual ward and it turns out they were only keeping an eye on my legs so I said to her it was a bit of a thing and I'd be giving you all my readings so she said oh you've got to see your gp about that because it's so right I really can hardly speak and she said I'm not able to see you he doesn't look back in we laid her exactly I'm back in here I think your we your legs are getting better yeah but the breathing's better yeah and tell me about the breathing what are your symptoms with that well it's just absolute I walk around up and downstairs without buttons up and got to the top of the stairs I have to sit down and if I'm walking am I gonna let her like all you'd have to hear at the top of your chest to breathe and I could go you know I can walk around the box downstairs doing little bits very little bits but the day I have to actually exert myself like into the toilet totally which I do want because I do wanna go up bed pads exactly I couldn't do it with like a walking stick mhmm and sometimes I breathe mhmm well I was doing it myself at bed sometimes but I never really breathe and you've got asthma is that right yes do you feel like this is the bad kick bad examination of your asthma or not well I never had a bad attack myself never had a bad attack until and then they thought well maybe it was a really bad accident and I followed the plow mhmm because I'm always controlling it did you you have a pack of steroids that you have at home is that right oh no no no the nurse gave you a new pretext of how many puffs to take if it was oh fine don't know I have nothing at home apart from puffers apart from your puffers you've got 2 inhalers haven't you I think you have a miss and they yes do you wanna see them I think I've got them on the computer don't I've never had a problem and normally yeah I do have to take extras in the summer of the heck because the hay fever is common or if I'm doing going walking and things only because and I use my stick as a sort of crunch in a way a mental crunch I'm with you yeah a bit of confidence from walking more than anything but it's never stopped feeling going right to the shop I don't feel little but this time and then taking you back so feeling short of breath not able to do the things you were able to do before reduced exercise tolerance any other symptoms cough oh it was a really bad cough okay and they thought I had I had a ct scan I saw that yeah and he said you got a lung infection possibly there wasn't a huge amount of evidence there but it was like cough cough and what were you bringing up in the beginning it was like horrible lovely bits of orange dark coloured brown stuff but now it's phlegm but it's very pale and it's more like spitty and then I explain it not thick but I know we'd love to make you have to cough then I had to start this is very embarrassing start putting a tangle in case I because you were coughing so much yeah fair enough but but yeah yesterday it was just as if I'd never been you know I I just back to getting it going and the coffee's carrying on the coffee's not as bad as it was not as bad but you're still there it's still there it's feeling a bit more dry at the moment but I think that's because I've been in this fine that must be there fine well I'm sorry about all this it is the breathlessness and is the breathlessness worse at any time of the day sore legs well when I wake up in the morning I take care of it puffer it's worse and then I say oh great I'm okay it's strange because going downstairs isn't a problem it's going up makes sense more exertional going up yes do you get symptoms when you're lying in bed at night do you wake up in the middle of the night gasping for breath no never have that it's cough in the morning bringing up orangey stuff initially and then that's got a little bit better and then got worse again normally I don't have anything up anyway you know only if I get sort of just the a normal day to day tell me about your life do they live at home with you no I live by myself that's fine I have a daughter who's very close that's good do have any pets or a cat and it's bad for asthma know but is it I don't know that's fine birds are definitely bad for asthma do you have any birds no the the girl that you know gifted a view I said no can't get rid of my cat you have anything yes I've got a cat I live in those and you live in a house or a bungalow I live in a house in a house with stairs yes and normally you're able to get up and down the stairs no trouble no problem but this has really knocked you back a bit sort of be even if I had to carry a bag of stuff mhmm I'd have to put it dead on each step as I carried it up mhmm because I couldn't carry the weight of that bag of course yeah fine fair enough have you ever had a bad asthma exacerbation before never in all these years and you don't really have any other past medical problems as far as I can tell no you're usually pretty well and what started off I had a jab for rsv this is 1 of first things and I went in to have it and I said to the girl the nurse that was doing it can you listen to my chest because I think I might get a chest infection and if I am I might say well what to have is jab and she said if you haven't got a range of fever or anything it won't make any difference but I haven't got time to listen to your chest I've only got 3 minutes so she told me to do an e consult so I went to go for the e consult the doctor phoned me up I gave him my symptoms and he gave me these steroids which was actually good to me then I did these pills but it didn't make me funny when I got here doctor said there you go didn't these funny things because my daughter said the same thing see that's what I need that telling lady of course and so we could go on and on can I have a look at your other hand is it alright just look at both your hands if that's okay yeah thank you and tell me about you what did you do for a living I was a librarian oh fine lucky around here yes I used to run 4 libraries oh wow great yeah nice and I didn't want to retire but you know they brought in the law when you were after 65 you could stay on mhmm retire and return or all that school well the case of I think it was a money saving thing everybody that I was 65 had just left to say you were not alone even seeing you by the drug but if I had been a year younger mhmm you'd have been okay yeah I'd be away needed set job yeah but yeah yeah well you could still go and volunteer or something like that yes well I was gonna but it seems a shame yeah I don't drive mhmm it's not a busy drive you can get there of course yeah alright I keep myself my brain active that's good if not the body how are doing good just have a quick listen to your heart oh I did have a very bad covid attack I lost all lost my hair oh good couldn't breathe it was really bad when was that when it first started really 5 years ago also had a jab and the doctor said which bitterly it was because I think I might be dying to be quite honest and it took me 10 months this is truly no exaggeration to walk from my house to the shop around the corner which was a hundred yards wow and since then this is what started it never been as good as everyone's back but it's never been the same yeah I've always had to take that stick with me just in case mhmm mhmm but before that I never had a problem with it and I'd lost weight mhmm you know thought but I'm that's really good and then my grand door kindly gave me covid mhmm oh dear my birthday was too but I was really bad and you know using your hair is not funny mhmm yeah let me have a look on the sun for a moment do you have a sit forward so I can listen to your back is that alright I can give you a hand if you need oh you're grand okay big breath whenever you're ready whenever you get a chance but no rush everything's good alright you want me to get back yeah just some breaths whenever you're ready ready and out and come back at the top okay thank you okay not too wheezy but a little bit prolonged yeah breathing out phase is much better I do think it'll sing my favorite but I can hear me walk as I came in you know can I touch your tummy do you mind just to make sure you're not got tummy pain or anything any pain passing water bladder and bowel's all okay good yeah allergic to anything well some absolutely when I was at the first attack it was the same but she was delayed I was having blood thinners mhmm and 1 of the doctors thought maybe I need to take morphine 3 times a day mhmm she gave me the sweet pill okay and I was was allergic to it the rivaroxaban or apixaban or something like that I don't know what it was but I don't know I ended up up here and I swung the tug of it oh gosh so they put me back on the warfarin I see she was just trying to be kind you're not on the warfarin now though are you only with them that was just for the pulmonary embolism I need I I do do yeah yeah you did a blood test to look and see how well your heart was pumping it was pumping very well yep very well indeed and was it I know that I had an accident once years ago full of the bus and I like tissue you know tissue damage this mhmm left a lump barely noticed that that's a bit of a you know that bit neck is sore sore is it sorry that 1 the other 1 when you touch it that side yeah yeah okay sorry it's alright but but we're just saying be gentle sorry you're done now so my heart is okay well blood test for it was good I mean it's a pretty good blood test really all things considered so I've got you all in a I could have gotten something bed doesn't no it's okay I'll take it sorry working so well I got sick I ended up developing a bit practically the same symptoms and that was why I thought maybe it was the same thing yeah yeah I wonder if this is an exacerbation of your asthma seems like the most likely thing yes it is I'll get you a misting mask to see if we can open your airways up and get you feeling better and take it from there do you drink or smoke no but I haven't drink it because I sort of forgot you don't smoking do you smoke or have you smoked before no not your thing fine yeah I can't see you've ever seen 1 of the respiratory doctors or ever had any lung function testing for the diagnosis of asthma is that fair to say is that where you blow through the pipe blow through the pipe you've had that yes fine at the gp maybe yes fine well because I have a last number of you every 12 months fine I'll have a look at when your last 1 was and see what it looked like yeah they're very good oh I I used to laugh and say you think it was a dead person blow me no because I never died properly but I did have quite a bit with last 1 okay okay I'll have a little look yeah and then we'll get you a bit of a misting mask and try and get you feeling a bit better from that perspective now yeah actually if I could just oh put you a I'll book you a jelly scan of your heart an echocardiogram just to make sure that the heart isn't causing the swelling of your legs it's like a it's like an ultrasound scan of your heart it just shows us how the heart moves oh it's rtc but it got like not it's not invasive or anything like that no sticking a thing in your legs no it's not an angiogram I wanted to have a ct scan then that's what this was for no this is for another a a ct pulmonary angiogram again really you already had 1 last week I did I said to him do I really need 1 because he took it and he said well I get back when did have some blood tests it's nice to have 1 of and said well I'm not sure he said but we'll and so he was going to get back and tell me I have to be there for 12 hours maybe he's forgotten came up to take me to the ward yeah so I don't know if this could cover the heart have you had a tracing of your heart yet what's that like when they put some stickies on your chest I'll have a moment I had 1 yesterday okay and 1 the week before fine he wants to care of it fine yeah you've weighed some normal x-ray yeah I've seen that there's no sign of a big chest infection or anything which is good so what would be caused no one's pregnancy so I I suspect it's an exacerbation of your asthma which can be caused by loads of things you don't need to have a pneumonia which is what we define as an infection visible on x-ray to have an exacerbation of your asthma it can be it could be just a viral infection that irritates the lungs we'll try I think we don't have a good test for it but we've got good treatments so I suggest we just try treating you and see if you get better what do they do with this jelly scatter we just see how the heart moves and it'll give us a bit of information about why the fluid is building up in your legs if the heart isn't moving very well then we know that we need to give you some water tablets to get things off those what they gave me didn't work exactly did they work no no that's why that's why I suspect that well I don't know if they were too weak I don't think I don't think your heart's the problem because the blood test shows your heart's not the problem but it's good to be a % sure with the jelly scan and yeah and take it from there so what I bet was what did it do on a jelly scan why is it called a jelly scan it's it's called an echocardiogram okay but they use jelly like you're scanning for a baby yeah but on your heart oh I thought we needed to how did they stick something else in oh god no nothing horrid it's just a probe that goes on your chest I mean see how your heart moves yes alright it doesn't make I mean eating the vegetarian it doesn't have anything to do with anything right no and your blood and your blood counts are fine you're not anemic or anything just yeah so you're getting enough iron yeah my right yeah my right is good alright thank you no worries tom it was lovely to meet you I'll get you to if we could just check it send out does it work you yeah it's very low it's just a low flow yeah that's lovely lovely alright no worries less than 2

Medical ST4 Miller Clerking

Presenting Complaint:
Breathlessness and cough.

History of Presenting Complaint:
- Increasing breathlessness, worse on exertion, particularly going upstairs.
- Reduced exercise tolerance; unable to do activities previously managed.
- Associated with a cough—initially productive of orange-brown sputum, now pale and more spitty.
- No nocturnal dyspnoea, no waking at night gasping for breath.
- Cough worse in the morning.
- Has asthma but never required steroids at home; has two inhalers.
- Recent RSV vaccination followed by suspected chest infection treated with steroids.
- Previously had severe COVID-19 infection causing significant functional decline.
- Leg swelling observed (was under virtual ward review for this).

Past Medical History:
- Asthma (annual spirometry at GP, last one noted to be ‘quite a bit’, details not specified)
- Pulmonary embolism (previously on anticoagulation)
- Severe COVID-19 infection (with prolonged recovery)
- No previous significant asthma exacerbations
- No mention of diabetes or other significant diagnoses

Medication History:
- Two inhalers for asthma (unspecified)
- No ‘rescue’ steroid packs at home
- Not currently on warfarin or direct oral anticoagulant

Allergic History:
- Allergic reaction to blood thinners (unspecified, possibly rivaroxaban or apixaban)

Social History:
- Lives alone in a house with stairs
- Daughter lives nearby and visits often
- Cat at home
- Former librarian
- Does not drive or drink alcohol
- Never smoked
- Uses a walking stick for confidence/mobility

On Examination:
- Slightly prolonged expiratory phase on auscultation, some improvement after misting mask
- No significant wheeze
- Peripheral oedema noted previously
- No abdominal tenderness, bladder and bowels normal
- Neck tenderness on palpation (old injury)

Investigations:
- CT scan: showed possible lung infection but not much evidence (exact findings not specified)
- Chest X-ray: no signs of pneumonia or significant chest infection
- Echocardiogram planned (not yet done)
- ECGs performed (yesterday and previous week)—no abnormality noted
- Blood tests for cardiac function normal

Impression:
Likely exacerbation of asthma—viral or post-infective, not classical pneumonia. Peripheral oedema with normal cardiac bloods (echo pending for further assessment).

Plan:
1. Nebulised bronchodilators via misting mask to open airways [_]
2. Arrange outpatient echocardiogram (‘jelly scan’) to assess cardiac function and rule out cardiac cause of leg swelling [_]
3. Continue monitoring for resolution of breathlessness and exercise tolerance [_]
4. Review inhaler technique and consider respiratory nurse review [_]
5. Consider further steroid therapy if symptoms persist or worsen [_]
6. Safety-net—advice to seek help if symptoms worsen or unable to cope at home [_]

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Summary:
Elderly woman with history of asthma and previous severe COVID-19 presenting with breathlessness and cough, likely due to asthma exacerbation. Awaiting echocardiogram to further investigate leg oedema.

AI Diagnosis:
Acute exacerbation of asthma, most likely viral/post-infective, with peripheral oedema of uncertain origin (cardiac function appears normal on bloods).

AI Plan:
1. Nebulised bronchodilators as needed.
2. Echocardiogram to rule out heart failure.
3. Monitor symptoms closely; escalate if no improvement.
4. Review and optimise inhaler use.
5. Consider oral steroids if no improvement.
6. Advise urgent reattendance if acute deterioration.

Summary

Investigations

Plans