Consultation — Patient with history of aspiration pneumonia and raised heart rate

Presenting Complaint

Raised heart rate this afternoon
History of recurrent aspiration

History of Presenting Complaint

Patient was sleeping this afternoon when concerns were raised
Heart rate noted to be between 98 and 100 this afternoon
Known history of aspiration pneumonia with four previous episodes
Patient not verbalising
Background history of Alzheimer's disease

Observations

Heart rate 98 to 100 this afternoon
Temperature 36.3 degrees
Blood pressure 101 over 68 currently
Blood pressure this afternoon was 136 over 77
Patient felt warm to touch but attributed to blanket

On Examination

Chest is clear on auscultation

Plan

No antibiotics started as patient is afebrile and chest is clear
General practitioner follow up tomorrow
Next of kin to be informed

Safety Netting

Call back if patient develops fever, shortness of breath or becomes unwell
Call 111 or 999 if breathing problems or pain develop in between

Transcript[00:00] S1: Salvation.
[00:01] S2: This afternoon she was sleeping.
[00:02] S1: Yeah, that's what they told me. Right.
[00:06] S2: Okay.
[00:07] S1: And then my colleagues check the observations, and the heart rate ranges from 98 to 100 or something like that.
[00:18] S2: This was this afternoon. The heart rate was 98 to 100 to 100.
[00:22] S1: It's. You want to wait?
[00:26] S2: Yeah.
[00:27] S1: You got this. This aspiration.
[00:30] S2: This aspiration. Has he had a temperature? So he's got a history of aspiration pneumonia.
[00:36] S1: Yeah. Yes, doctor? Yeah, I think, like I said already, already four incidents of aspiration.
[00:45] S2: I'm. Just gonna stick. Sorry. Has he been confused or.
[01:16] S1: Just not verbalizing doctors?
[01:20] S2: Feels a bit warm.
[01:21] S1: Yeah.
[01:22] S2: Maybe because of the.
[01:23] S1: The blanket.
[01:25] S2: I think it's blanket. The temperature now is 36.37 just now.
[01:32] S1: Check it, I think. Hour or less. Hours 36.3.
[01:41] S2: So is. The examination chest is clear. Okay. History of stroke or anything.
[02:17] S1: That is in history.
[02:18] S2: No. History.
[02:19] S1: Aspiration. Pneumonia.
[02:21] S2: Alzheimer's. Aspiration.
[02:24] S1: Aspiration pneumonia.
[02:27] S2: Blood pressure 101 over 4168. Is that normal? What was the blood pressure this afternoon?
[02:34] S1: Let's take a.
[02:35] S2: Look.
[02:50] S1: What pressure is? One 3677.
[02:55] S2: That was this afternoon. So now.
[02:57] S1: Yeah.
[02:58] S2: Yeah. So now it's a bit similar. Yeah. I mean it depends. I think the best thing is if he settle at the moment and sleeping, the best thing is follow up with the GP tomorrow. Okay. And then we write that the GP. All right. See what they say. Because he doesn't have a temperature I don't want to start antibiotics or anything for no reason. If anything changes, if he start developing fever, he had shortness of breath or he becomes unwell, then he just gives us a call back. Otherwise GP follow up tomorrow. And then safety net is anything happens in between breathing problems. He's in pain or anything. Call 1114999. But I think just I think it's good that you called today. At least we can check him over. But chest sounds okay. It doesn't sound too too bad, right? I mean, as clear as we can see from here, right? Because we can't really see him properly. Okay. Yes. Okay. All right. He's got next of kin.
[03:54] S1: Yes. Next.
[03:56] S2: You can inform them.
[03:57] S1: I will, I will.
[03:58] S2: Yeah. Okay.