So it's clocking for peter johnson delta051726 84 year old gentleman presenting complaint unresponsive episode investigations okay how are you I'm good thanks how are you yeah nice investigations crp 16 creatinine 235 urea 19.2 potassium 5.9 her recent bloods demonstrate creatinine baseline 150 back in august 2024 however 02/2023 on the june 5 with egfr 21 currently calcium phosphate normal alp 1 7 3 troponin 1 6 5 and 216 magnesium low at naught 0.65 inr 1.8 hemoglobin 77 was a 112 back in august 2024 with low red cell counts low mean cell volume and low mean cell hemoglobin neutral 6.6 white cells 8 blood gas ph 7.32 carbon dioxide 5.35 add to the plan replace magnesium intravenously cardiology review check hematinics echocardiogram past medical history peripheral vascular disease left sided duplex 50 to 74 stenosis of the left popliteal artery leading to slow to heal left hyperkeratotic fissure also has obstructive sleep apnea for which he uses cpap has hypertension and paroxysmal atrial fibrillation type 2 diabetes ckd complex stenting for the left main stem and right coronary artery in march 2019 following an acute presentation what's the difference in is it I've actually got persistent atrial fibrillation I've fibrillation beautiful the doctor who set nerve center up for 1 month to find that it might help us most recent echocardiogram august 2024 so they're switching out we're gonna use the chaperone just normal lv size with preserved lv systolic function ejection free fraction in the region of 60% reduced longitudinal function mild tricuspid regurgitation dilated right atrium low probability of pulmonary hypertension left pleural effusion atrial fibrillation in the past medical history we also have bilateral cataracts background diabetic retinopathy for the past medical history describe it as type 2 diabetes mellitus with retinopathy and nephropathy most recent h b a 1 c 56 in august 2024 medications list linegliptin 5 mg once a day lanzoprazole 30 mg once in the morning isosorbide mononitrate modified release 60 mg tablets only taking 30 mg once a day ramipril 5 mg a day spironolactone 25 mg once a day rivaroxaban 15 mg once a day dapagliflozin 10 mg once a day clopidogrel 75 once a day atorvastatin 80 mg once at night doxazosin 2 mg once a day glipizide modified release 30 mg once a day on examination the observations which is respiratory rate 17 sats 100% on 4 l oxygen systolic blood pressure a 137 over 58 pulse 64 temperature 36.1 afebrile most recent blood glucose 9.1 no but the water's good for seeing you stop at the and I'm on the right red man is built up and my mom is a nurse another appointment in the hospital somewhere goodness fine fair enough yes he's in for a heart attack so how's he doing he's okay he's not a bit confused ask him the same question otherwise he's locked he's holding his heart in the same time so that's okay she's not normal then yeah she's not normal not normal okay alright doesn't remember anything even though my sister was there earlier there's something wrong with her so mhmm I need to wake at a time to talk to her so don't know being a nostril can be a very disorientating hi I'm rob I'm 1 of the doctors nice to meet you mr johnson how are you I'm fine at the moment good I'm glad what do you remember about what brought you into hospital maybe all of a bit of a blur well I've got various things on I've read all about that yeah and for some reason yesterday although I had my heel and toe dress when I got home I felt absolutely wrong and then during the night my wife decided that I wasn't well you came to the hospital in what way did you feel rotten in what way did you feel rotten not with it and not well not right I would normally slightly confused possibly or just a bit muddled or is that what you're describing is not right or no I don't think confused mhmm okay fine the right way more like how much your levels maybe brad just not feeling well yeah okay I understand just generally unwell okay so you're generally unwell yesterday and then what happened in the evening may be a bit of a blur I understand you use cpap for your obstructive sleep apnea is that right fine you use that every night yeah fine and put that on I understand and then you said your wife noticed you're becoming more unwell which is exactly right and I think you had a little funny turn out of bed and bumped your head is my understanding is that your understanding as well so my understanding is that you hadn't gone to bed you were in a chair thank you I've always been taught that alright but I've noticed was it you who got up to the toilet or was it mom who got up to the toilet realized you hadn't gone to bed was helping you into bed uh-huh and because you struggled to lift your legs on your own so you were sat in bed and mom was lifting the legs and she did 1 the alarm was very heavy she went oh come on give me a hand and looked up and you were just you had gone mhmm and she couldn't feel the pulse mhmm couldn't get any bleeding very well yeah okay alright but you seem to be alright now which is important some message to us hello hello hello use nurse center as normal nurse center and since you come into hospital we've seen your heart's going in a bit of a funny rhythm it was going quite fast earlier but now it's slowed down quite nicely I think you've been having you've had that atrial fibrillation for quite some time yeah so that maybe isn't a new thing a marker of heart damage the troponin is slightly raised but not massively increasing which is good but it may be that when your heart was going fast it stressed the heart out a bit which is quite likely but we haven't really found out what caused that episode you had of being vacant and possibly stopping breathing it may have been that your heart was going very fast at that time which caused you to momentarily lose consciousness and that that sorted itself out certainly the ambulance crew found low oxygen levels when they came to you and so there may be a respiratory component as well have you had quite a cough or cold or anything like that I could get sore throats quite a but not over the last day or so nothing out of normal after usual no any fevers or anything like that nothing alright I just generally feel yuck and we can explain why you might feel yuck because you're quite anemic on your blood tests your blood counts are quite low it looks like you've been anemic for quite some time you 6 months or so I would say just slowly trickling down looking at your blood tests it looks as though the iron levels are quite low in the blood and that could be caused by lots of things do you notice any bleeding anywhere sorry do you notice any bleeding anywhere no but I've had my doctor did a and they said the bleeding and on a on a stool test yeah when when you wipe with the paper yeah the special paper that you they they send off the bowel cancer screening 1 fine mhmm so you had a a raised fit test the test of blood and stool yeah and I think I read about that as well yeah but have you noticed any jet black tarry stools that more so have you noticed a change in the color to your of your stools are they are they jet black getting darker getting darker like black like and gray like my trousers or or a brown kind of color a bit lighter than yours brad a bit lighter but getting darker and more and more brown more brown that's good more brown than black good it does occasionally come out black is it loose and black no does it stick to the pan and you can't flush it away no it flushes away fine flushes away okay all right fine good to know and any shortness of breath or anything like that yeah yeah I know you've had that for a while but has that been worse over the last few weeks well I I wear a cpap at night yeah which I've done for a number of years mhmm and just recently it's got a bit worse mhmm this is a staff analysis I'm gonna go do has it since you have the ulcer just before the last sir it's never healed properly it was the operation on it was the end of last 2 lives and it still is bleeding I'm saying and did you have an angioplasty in your leg did you have an angioplasty in your leg where they fix the vessels or what or did you have a where they scrape the side of the ulcer to try and make it heal what kind of operation did you have I had stents I read about that it's it's just a case of not healing quickly I see and it's it's about that much more to go mhmm before he fell out healed up the skin to I understand yeah fine poor mhmm great gonna have a little look at you can you look at your leg do you mind yeah what are gonna say issues with your like issues with your circulation as well so they didn't want to put dye in and things like that into your legs because of your oh yeah was you've got peripheral vascular disease in that luckily hold of our arm I'll pull the catheter and have a look alright what are you doing all nicely dressed isn't it you're massively warm it's on your heel isn't it so I'll try not to prod it too much it does tend to wake and hard does it you've also got 1 at the top of your toe and mom said that's not healing either oh no it's perhaps at the end of the day end of the day it's a bit swollen yeah alright but not over the last few weeks that's a bit of a headache normal mhmm nothing abnormal announcement please revert from vcps your nerve center is fully operational got a little murmur in your arm I think we knew about that from your last jelly scan of your arm that 1 of the valves is is slightly heard up but nothing changed from before go and listen to your back do you mind do you want me to sit for a while thank you take breath whenever you're ready good breath good breath and again that's good thank you can I have a look at your tummy is that alright how are your bowels doing you don't need take anything off don't worry they're alright it's probably I guess darker yeah we talked about it's darker when's the last time you went for a pee when's the last time you went for a pee so it's an area narrow great and how about a wee mine still isn't it no that was for a wee dad not for a pee I just couldn't do it have you been for wee was that was an hour ago in the house okay and it was and that was short through the night okay fine there's that 1 in there today okay great I'd to have a look at your chest x-ray which I hope you've had my system was down as I'm sure you've heard we couldn't look at it but now it's back up running I'll have a little look at the x-ray which I hope you've had most people coming to recess will have an x-ray but if you haven't had 1 I'll arrange a chest x-ray for you it sounds like you've a bit of fluid on this right side of the chest which I knew you had before but may have got a bit worse and may be needing the reason you're needing a bit of oxygen yeah we can make sure you get your sleep apnea at night for your sleep apnea but wouldn't normally cause you to need oxygen during the day I would hope your leg swelling is certainly significant isn't it up to your hips and it may be that the heart not moving fluid is what's driving the fluid on your chest most likely and I suspect that funny episode he had was a combination of low oxygen levels because of the fluid on your chest as well as the heart going into that fast funny heart I know I read about that yeah so I suggest we tinker with your medicines increase your diuretics slightly to try and get this fluid off while keeping a close eye on your kidney function because we know that it would send your kidney function off slightly but we can tolerate a slight worsening in your kidney function to try and get this fluid off your chest alright to try and get your breathing a bit better if that's what the chest x-ray shows which I suspect it will I'll add on a few blood tests to look at the cause of your anemia I suspect it's an iron deficiency anemia yeah I've I've already got iron tablets mhmm do you take iron tablets haven't had it up today yeah fine because nothing here fine fair enough so the iron tablets can certainly make your your stools a bit bit darker I didn't see them on your gp record that's fine sometimes they slip through the net the iron tablets how often do you take those 3 times a day or twice a day once once a day fine so you're just on them yeah alright so you're taking some I'll add those to your medicines that you get while you're in hospital topping up your iron levels is very sensible I think instead of rushing in to investigate with horrible tests like colonoscopy to see what's causing it I think it's probably a bit academic to see you may have a polyp causing it but it's slightly academic taking you off the blood thinners to take the polyp off will be incredibly dangerous for your heart and I think it's not worth rushing in to do something like that so we'll leave that by the by and keep topping up your iron levels I think that's entirely sensible you may need a top up of some iron through a drip while you're in hospital which would be a good 3 months worth of iron so we could do that while you're in as well and then we'll take it from there we'll keep an eye on your blood tests every day we'll try and get the fluid off as best we can to try and improve your oxygen levels okay alright alright any reasonable gonna be in for a long time it's it's this that keeps you in this oxygen once you're off that then we can try and get you out of here but it's very difficult to say how long that will be I would suspect it'll be a good few days sort of what does it say thursday I would think the rest of the week and the weekend at minimum to try and get this fluid off okay is that okay fine any questions anything I've forgotten only 3 things my mum has stopped me today for my daughter yeah I know yeah I've heard about that he potentially might have clearly a cancer yeah which you know obviously they're they were gonna tell me at some? This week and see what's happened yeah I I don't know what tests he's had or what yeah I haven't had any investigations for that I guess that's what I was kind of talking about the polyp in the: he he hasn't been drinking this morning fine perfect we would so I'm a gastroenterologist by trade but I'm doing all the medicine today we would usually investigate iron deficiency anemia with raised blood poo levels with a colonoscopy but it's a very invasive test the prep is significant it really hits the kidneys and it hits the heart as well so it's not going to be the right test for you and as I said if there is a cancerous polyp there taking off your blood thinners to take that polyp off would be incredibly risky I think topping up your iron levels is very sensible and it's impossible to say what's there without investigations but all of those carry a risk and if it won't change what we do I don't think it's worth rushing into that to do that and it's a you know a big spectrum of things you know: cancer could be a small polyp that's slow growing and doesn't do anything or it could be something aggressive aggressive either way I don't think it'll change what we do would be the irons as well so is that going be via that through blood cells yeah so so we can give them you an infusion of iron to top up your iron levels yeah a drip of iron we can do that while you're in hospital I wanna make sure you haven't got an infection because it can it worsen infection so I'd like to see your bloods tomorrow to make sure your inflammatory markers aren't coming up if they're not then fantastic we'll give you some iron but I think we need to keep and just hold fire for for a day or so alright does that make sense great okay okay come on brill it was nice to meet you very much nice to meet you great thanks for coming