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 investigations chest x-ray right moderate and small left pleural effusions similar to previous chest x-ray in august 2024 but hazy pacification to the upper zones in the right new no not that much no now okay so this is the lazy day it's been the single day and the history of setting complaints episodes of bradycardia noted by ed team is what we're doing with witnessed episode of bradycardia symptomatic that'll be a of impression episodic slow atrial fibrillation leading to type 2 mi titrate diuresis increasing furosemide to affect is he on furosemide no add to the medications list tuo duo t u o j e o insulin alright plan digoxin levels that's the plan admit medicine monitor bed input output monitoring continue direct acting anticoagulant and antiplatelets increase spironolactone to 50 mg daily u and e hi hi I'm robert I'm 1 of the med growth stars nice to meet you we didn't chat earlier but I think you witnessed the episode so it'd be great to hear I was just came back to just find out a little bit about what happened from your perspective is that okay sure yeah when I was making a mistake I putting my toe in the I was just see people who was prominatory with diane and I was gonna go to bed and I was gonna get him to bed and then he called me in can I help to get his legs into bed because she knew how to go yeah how many legs well I got 1 up went to get the other 1 up and nothing was happening there was no help so I looked had to look around and what's going on and his eyes were half open I was hardly I don't think he was even breathing or anything at that stage it was just nothing goodness yeah fine so that was it but he's at all okay fine and how long did that episode last did he come around before the ambulance crew came no no fine so it must have been yes 30 minutes oh yes him in that state 15 minutes 15 minutes say the day was 41 okay alright fine and then when they arrived they didn't do cpr or anything they found you to be breathing I understand but low oxygen levels right is that right yeah fine you know mate that's fine yeah that's fine yeah then I've asked this our computer system as I'm sure you've heard has just come back online so I was able to read what the a and e team have said overnight they witnessed another episode similar to this where you went a bit a bit out of it a bit sleepy and on our monitor it looked like your heart was going very slow and I note that in the past you were having these episodes of going fast and slow with this atrial fibrillation which can happen and the heart goes fast and slow so I suspect what happened is the heart went quite slow you weren't able to make much blood go to your brain so you were quite sleepy you also weren't able to make much blood go to your heart muscle which meant that your heart muscle's taken a bit of a hit and not much blood has got there which is what's important that heart damage marker up your chest x-ray shows that you have got some fluid building up on the right similar to how it was before but there's also some fluid in the lung tissue so probably that's related to these episodes of going slow and getting that off with some increased water medicine would be quite sensible so we'll carry on the plan as before but we'll keep a really close eye on your heart while you're in keep the pads on your canal and then we can keep you in a monitored bed while we bring you into hospital if we document these episodes that may be a sensible thing to do to buy a pacemaker and to try and stop these episodes happening but we need to see them happening and capture it on the monitor so that we know exactly what rhythm it is I'll speak to my colleagues in cardiology to make sure they're happy with that as a plan as well so you're going to sort all that side out before you do the exercise so I don't I think we that we spoke a little bit about the cancer side so I'm a gastroenterologist by trade so it's kind of my area you've got low iron levels with some blood in the poo that can be from a polyp it could be from a cancer it's impossible for us to say without an invasive investigation either a colonoscopy which requires significant prep would really hit your kidneys and in order to take a polyp off you'd have to stop all your antiplatelet medicines which would really hurt your heart which has got stents in so that would be a very risky thing for you to do we could do a scan but that requires contrast as well which would also hit your kidneys I think even if we found out something was there it would be quite academic I don't think it would change what we do and you could have just a polyp there that's just oozing a bit of blood or you could have a cancer in your: it's really difficult for us to tell but I don't think that going in and rushing in to do an investigation is the right thing to do because I think it won't change our management does that make sense and these investigations come with risks and it would be a shame to do a test just to find out if what if kind of test but actually it causes you a major problem and hits your kidneys which can back up to your heart and all this stuff does that kind of make sense fine is confusion all that good I hope so because obviously being in hospitals a disorientating confusing place for any of us and you've had episodes of not much blood going to your brain which could make you feel a bit confused so I'd hope that that will improve certainly during this admission and if not soon after getting home I would describe this as a delirium which is a very common thing that happens to people in hospital when they're acutely ill we know that a third of people it gets better during the admission so all within a few weeks a third of people it's more prolonged so it can take 6 to 8 weeks to get better and a third of people it gets a little bit better but not completely back to normal and those people end up getting a diagnosis of dementia but I think that it's given you a fine before you came into hospital as far as I understand pretty good then I'd hope that you'd be in those 2 thirds at the start does that kind of make sense there's some talk about from the ed team speaking overnight about jumping up and down on your chest if your heart were to stop what kind of discussion did you have about about that about resuscitation they said that it was not a good idea I think I'd agree with them cause more problems yeah I think I think to have I think he's going he's giving his weight to dan but I didn't understand the doctor and the doctor was talking about okay then me me and my sister walked away and he was disgusted with dan and dan so it was still he wanted to be out of of torn down his foot and so I think if your heart were to go very slow and we watched it on the monitor I think shocking you is fine and I think giving him stronger medicine to make your heart go faster is very sensible because there's something reversible there but when people's heart stops in hospital after a significant deterioration over days and weeks of trying everything and it doesn't get better I think that's the kind of cpr I'm talking about which is like a last ditch effort where if it were sort of me or roma suffering it we would have a 10% less than 10% chance of survival but if it were someone like yourself suffering it the chance of survival of any meaningful recovery would be 0 I think and so I'm not saying that's going happen but I think planning for those things is sensible so I think that carrying on giving strong medicines shocking you is really sensible but I think that jumping up down your chest is not the right thing to do and I think it would be an undignified way to go undignified way to go personally is that alright okay cool I'll make sure all of that sorted any questions for me god you asked some questions but I don't know if you can start thank you so kidney I know that kidney is hungry every day is there a deterioration since the last time is it so not since the last time you well when were you last in in august yeah august 2024 so it's worse than that but it's not worse than the blood test last week the fifth or a week ago on the june 5 if that makes sense so on the june 5 the blood tests were you know they have the kidney function has worsened you were at 31% and now you're at 21% but in the context of acute illness we usually do expect a slight deterioration in the kidney function I think that with everything that's going on we know your vessels aren't great because the vessels in your leg are affected by the diabetes and the vascular disease if you've got problems with your small vessels in your eyes with the retinopathy and with the vessels in your legs you're going to have problems with the vessels in your kidneys they're such tiny vessels and so when they clog up we do see that gradual deterioration you take insulin for the diabetes is that right not now you start to yes fine that's good to know alright and because your your blood glucose levels your hba1c is actually not bad is it 56 56 yeah very good so you're doing everything you can to control it but unfortunately we still see that deterioration yeah and unfortunately the kidneys and the heart just don't agree with each other much when the heart's unhappy the kidneys become unhappy and then they make the heart more unhappy and so they're just fine balance exactly it is a fine balance it's small tinkering with things yeah I thought of something then sorry I just what should I be looking out for when he gets home is there something apart from him just going roosh well I'd hope that we'd have sorted that out the going roosh think we've got an explanation for that with the slow heart rate and I'd hope that we'd sort that out while he's in hospital with having say a pacemaker or changes to his medicines I know that I know that you are sick so I'd wanna check your digoxin levels and make sure that that's not too high because that can sometimes make the heart go quite slow so there's a few things to check-in the background the hemianemias mhmm yeah I'll check all of those bits and bobs in the background but I would expect that that will be sorted I think bleeding from downstairs is obviously a worry if the if the poo is jet black sticky difficult to flush away then we should be concerned but in terms of the atrial fibrillation think even it's a new thing that you weren't expecting and I think going into hospital is very sensible for that I think there's huge amount that you can do at home other than other than bring him in right that kinda makes sense so we put a lot of iron sort of in the future obviously there's something's happened that's reduced it so moving forward it it just leaked him out of his color his energy levels yeah and he starts to dip there exactly he does look quite pale to me I don't know about you guys if you're looking at his color more and more yellow rust or yeah waxing the last couple times of like visits over the last few weeks I didn't visit last weekend but a week it's probably more noticeable if you're seeing it in steps isn't it than every day he's very very similar it wouldn't have been to see a productive weeks ago us men are like that aren't we yeah so I think looking at his colours is you can see whether he's anemic from that whether he'd need another exactly infusion of iron or top up or increase in his iron tablets but like I say when you're in hospital and we're monitoring it every day can see those trends a lot easier we can see that despite the iron tablets blood counts are dropping and we can think maybe you need more iron tablets maybe taking them twice a day would be sensible although they come with more side effects of taking twice a day or regular drips of iron infusions of iron I see you vomited last night and that was not long after you had the peristaltate so and I know that's a side effect isn't it sometimes bad medicines really they are they cause a lot of problems the bowels to vomiting was gastritis last night gosh it's been ages since last night course yeah did you did you eat much yesterday because your appetite's not been very much no do you any drink mhmm do you have no you didn't you had ice cream that was all you would have you're baby dad that's fine I'll leave it to you as I'm sorry to disturb you but it's nice to talk to you alright if you have any questions on the other day I'm cracking okay thanks see you bye that's my patient's name