Physician's Assistant

MRN:

Content:

Medical ST5 Miller Clerking
Date: 26/02/2026 15:11

Presenting Complaint:
Acute breathlessness

History of Presenting Complaint:
An 83-year-old lady with a background of heart failure with moderately reduced ejection fraction (EF 35–40%), permanent pacemaker, type 2 diabetes mellitus, CKD stage 3, and asthma was brought in by ambulance following a 3–4 day history of worsening breathlessness. Collateral history from the ambulance crew noted she was found sitting upright in a tripod position with increased work of breathing.

She reported feeling constantly short of breath for the previous 3 days and was unable to sleep due to orthopnoea. No PND. She denied cough, sputum production, fever, or feeling systemically unwell. Breathlessness was exacerbated by exertion and lying flat. She had visited her GP the previous week, where her inhaler doses were increased; however, this did not improve her symptoms and she had been using her inhalers more frequently without benefit.

She denied chest pain. Her previous presentations with ACS were associated with chest pain.

She was admitted in May 2025 with an NSTEMI, which was medically managed. This was followed by decompensated heart failure with reduced ejection fraction. She is known to the community heart failure team. It is noted that her diuretic was switched from bumetanide to furosemide in October 2025.

Past Medical History:
• NSTEMI - May 2025 (medically managed)
• Heart failure with moderately reduced ejection fraction (EF 35–40%)
• Permanent pacemaker — inserted for tachy-brady syndrome
• Pulmonary embolism — 1966
• Hypertension
• Type 2 diabetes mellitus — diagnosed 2013
• Asthma
• CKD stage 3 — baseline creatinine 78
• Osteoarthritis (bilateral knees)
• Diverticular disease
• Macular degeneration
• Bilateral cataracts
• Vitreous detachment — 2024

Drug History:
• Salbutamol (Ventolin) 100mcg inhaler 1–2 puffs INH up to QDS PRN
• Furosemide 40mg PO BD (started 10/2025, replacing bumetanide)
• Tiotropium (Luforbec) inhaler 1–2 puffs INH BD
• Sertraline 100mg PO OD
• Candesartan 4mg PO OD
• GTN spray 400mcg SL 1–2 doses PRN
• Aspirin 75mg PO OD
• Atorvastatin 40mg PO OD
• Lansoprazole 30mg PO OD
• Bisoprolol 1.25mg PO BD
• Famotidine 20mg PO OD
• Humulin M3 KwikPen — dose not specified
• FreeStyle Libre sensor
• Carbomer eye drops
• Metformin 500mg PO BD

Allergy History:
Patient states NKDA

Social History:
Living situation: Lives at home with her partner.
Mobility: Mobilises with a 3-wheeled walker. Gets out of the house approximately twice per week - attends church and visits her daughter.
No POC
Functionally limited by both arthritis and breathlessness. Unable to walk far on the flat. Breathlessness and arthritis both contribute to reduced exercise tolerance.

On Examination:
Initially narcosed with hypercapnia but now alert and chatty although still SOB
Observations: HR 97 bpm, BP 130/80 mmHg, RR 21, O2 sats 97% on BiPAP (CPAP 7cmH2O, FiO2 25%). Monitor shows visible p-waves.
• Cardiovascular: Pacemaker in situ. Broad complex tachycardia on ECG at presentation — rate 140 bpm, consistent with VT but AF with bundle branch block also possible. Repeat ECG required. Quiet heart sounds.  JVP at jaw
• Respiratory: Coarse crepitations to MZ bilaterally.

Investigations:
• Hb: 121
• WCC: 18.3
• Neutrophils: 12.86
• Sodium: Normal
• Potassium: 5.7 (previously 4.8 in January 2022)
• Urea: 8.3 (previously 11.5)
• Creatinine: 78 (patient's baseline)
• ALT: 35 (previously 15; other LFTs normal, no jaundice)
• AST: Normal
• Phosphate: 1.63
• Magnesium: 0.68
• CRP: 10 (noted to be chronically raised)
• Bone profile: Normal
• Troponin: 24 (previous troponin 28 in May 2025)
• ABG on presentation to ED: pH 7.22, pCO2 8.6, Base Excess -2.6
• ABG following initiation of BiPAP: pH 7.30, pCO2 7.2, pO2 8.3, Base Excess -0.6
• ABG most recent: pH 7.36, pCO2 6.4 (demonstrating continual improvement on BiPAP)
• ECG (presentation): Broad complex tachycardia at rate 140 bpm — consistent with VT; AF with bundle branch block also possible
• Chest X-ray: Bilateral perihilar infiltrates consistent with pulmonary oedema; infection within the differential
• Echocardiogram (May 2025): EF 35–40%, impaired LV systolic function, dilated LV, mild MR and TR, intermediate probability of pulmonary hypertension, mild aortic stenosis in low flow state, biatrial dilatation

Impression:
Decompensated congestive cardiac failure with type 2 respiratory failure due to tiring
- Missed MI vs switch from bumetanide to furosemide as underlying aetiology

Management Plan:
1. Cardiac monitoring, 
2. Repeat ABG 1 hour after switching to CPAP
3. Repeat 12-lead ECG
4. Repeat troponin
5. Daily UE with ongoing diuresis
6. Switch from BiPAP to CPAP now that acidosis has resolved (pH 7.36). Reassess ABG 1 hour after commencing CPAP. Aim to wean CPAP as oxygenation improves following further diuresis, likely to continue CPAP overnight
7. Furosemide 80mg IV BD
8. Isosorbide dinitrate infusion — wean as oxygenation improves and following further diuresis
9. CCU bed — discussed with Cardiology Consultant Dr Felmeden, who agrees with CCU admission
10.Family update
11. Escalation plan: RESPECT/TEP form in place, previously discussed with GP — ward-based care only; not for CPR or ITU admission.

Summary:

Investigations:

ABG on presentation to ED: pH 7.22, pCO2 8.6, Base Excess -2.6
ABG following initiation of BiPAP: pH 7.30, pCO2 7.2, pO2 8.3, Base Excess -0.6
ABG most recent (26/02/2026): pH 7.36, pCO2 6.4
Hb: 121
WCC: 18.3
Neutrophils: 12.86
Sodium: Normal
Potassium: 5.7 (previously 4.8, January 2022)
Urea: 8.3 (previously 11.5)
Creatinine: 78 (patient baseline)
ALT: 35 (previously 15; other LFTs normal)
AST: Normal
Phosphate: 1.63
Magnesium: 0.68
CRP: 10 (chronically raised; not significantly elevated for this patient)
Bone profile: Normal
Troponin: 24 (repeat required; previous troponin 28, May 2025)
BNP: >1600 (May 2025)
ECG (26/02/2026): Broad complex tachycardia rate 140 bpm on presentation — consistent with VT; AF with bundle branch block also possible. Repeat 12-lead ECG required.
Chest X-ray (26/02/2026): Bilateral perihilar infiltrates consistent with pulmonary oedema; infection within the differential
Echocardiogram (May 2025): EF 35–40%, impaired LV systolic function, dilated LV, mild MR and TR, intermediate probability of pulmonary hypertension, mild aortic stenosis in low flow state, biatrial dilatation

Patient Details

Refined clerking Thu 26 February 2026 15:11

Field Clipboard (for EPR paste)

Tasks

Feedback