Notes

Mr George Cornish presented under same-day emergency care on 29 Oct 2021 with a PC of "general decline" and a history of refusal of meals resulting in decreased medication compliance. On initial examination, A&E team observed abdominal tenderness with guarding. There was also suspected decreased urine output. Mr Cornish could not give a history due to aphasia likely from his history of vascular dementia and a lacunar stroke. This gentleman is housebound with previous illness of COVID, focal epilepsy, and long standing hypertension as well. On admission to the ward, history could not be completed but mild abdominal tenderness in the suprapubic region was observed. Mr Cornish was and continues to be alert and conscious with no signs of cardiac-respiratory decline or reduced GCS. He was given IV co-amoxiclav via cannula placed on 30 Oct for treatment of suspected UTI. No mid stream urine sample has been taken due to gross incontinence. Mr Cornish was also given paracetamol for as required pain relief. He was also given pabrinex due to his lack of appetite and lactulose,and enoxaparin & clopidogrel for PMH of CVA. He was continued on ongoing medication of levetiracetam and sertraline, has also been reviewed and cleared by the SALT team, with input from dieticians. NEWS score was fluctuating between 0 and 1, but as of today as returned to 0. Recent clinical examination (2 Nov) did not reveal any abnormalities, and patient was able to communicate that he is not in any pain. He appeared well hydrated and in no distress. He has been on a normal diet and needs continued assistance with eating which he is set to continue in his care home under the direction his next of kin.
Overall Mr George Cornish is currently medically well with no signs of an active infection, and resolved clinical symptoms. His observations are stable and he is currently fit to be discharged.

A&E bladder morphology consistent with outflow impedance, with hepatic cysts of no clinical significance. CT abdomen revealed no significant abnormalities apart from colonic diverticulosis and outflow impedance. Bloods were taken on 31 Oct 2021 revealing a CRP of 6, Vit D deficiency (13 mmol/L) and slightly low leukocytes (1.1) and RBCs (4.44). CRP was initially 6 and today was 8. But overall decline in values from 38 relative to previous history from 5 Oct 2021.
Otherwise FBC normal, with coagulation screen, TSH, Folate and B12 within normal range. These results did not have any clinically significant change when re-done on 1 Nov.
Continuous negative COVID swabs.