Transcription - 20250627T 14-35.mp3

As deck for Scott powell 9 4 678 6 investigations urea 8.4 creatinine 78 baseline 73 that's normal nt probnp 1,274 inr 1 full blood count normal blood gas normal apart from glucose 6.1 past medical history rachel flutter may 2025 sarcoidosis 2013 central hypertension 2010 medications list apixaban 5 mg twice a day to prevent blood clots bisoprolol 5 mg once a day mhmm investigations chest x-ray isolate lymphadenopathy but no signs of focal infective etiology from the 05/31/2025 ecg baseline rate of a 144 atrial flutter so you're feeling okay on yourself yeah yeah fine so what's what's made you come in tell me so I had I had for about a. Of about 3 weeks I've been experiencing pins fluttering so that prompted me to come to the following day that was the may 30 yeah so came up they checked it so yes you've got an atrial flutter yeah and you went on some hixaban and some bisoprolol yes yeah yeah so I then went for I think it was about a week later they had the the the just to make sure that the bisoprolol was actually lowering my heart rate they checked it then and they found decrease your dosage to the bisoprolol you were on 2.5 before yeah mhmm no I was on 2.5 and and and then they they did to like 3 yeah something and then 3.125 yeah they put it onto the 5 and then I it was a case of just see how you get on with that yeah and then today that I had myself booked in to to go in for basically another check just to make sure it was managing it but when they checked checked me today my heart rate again was a 146 yeah so I've not actually been feeling unwell okay good I hadn't really been feeling the the fluttering I'd get like every now and then I'd I'd I'd feel it a bit but whereas previously I was getting it a lot and also when I was lying down I was feeling the the racing in that but since I've been on the tablets when I've been lying down I haven't felt okay I haven't felt that have you been feeling okay on the tablets you've been feeling fatigued or anything like that not fatigue I mean I I have had a bit of a chest infection which was which I'm I've I've on some antibiotics k but after 3 days on it I was feeling loads better mhmm those were doxycycline where you were doxycycline yeah yeah but I hadn't really noticed any any I thought I was feeling fine until we I was quite surprised when they said that your heart rate's like a 147 mhmm only thing I did ask from at the time is I said that actually since you've increased my vitals of sopranolol to the 5 mg yeah my ankles starting up yeah from the from the calf downwards are really are really sort of retaining fluid okay but if it's a weekend and I've just been walking around that by the end of the evening I won't get well he's on really wow and tell me about your life more generally do you work yeah what do you put in so I work in a factory okay so I'm an engineer in a in a factory I work nights okay so I'll numb my feet all night so I'll easily do 10,000 steps yeah yeah so I'll easily do my 10,000 steps in a number 3 days or if I'm either you know more than your kids 1 or just just the 1 that I need to walk into school yeah fine and then just general mhmm tottering around you know mhmm mhmm so that's pretty much pretty much it fine and and then do those things yeah fine so you don't drink alcohol like occasionally very rarely yeah do you drink loads of coffee on your nightshares no I've actually stopped drinking coffee I I don't I'll drink only drink tea yeah at home okay how many cups of tea are we talking day okay through the course of the day okay and then obviously you've had this chest infection what were your symptoms did you have a cough or yeah well I I I had a no real sort of like sinus yeah issues with it it was all on the chest chest so feeling like when I was breathing I was getting out of breath almost like I couldn't like fully yeah oxygenate okay and I'd I'd go to sleep and when I woke up I'd I'd be there you know a lot of guitar and phlegm and that before I could really and what kind of stuff came up nothing really like dark in color and frothy no no quite solid solid but then I was just feeling fatigued and really tired and that's what because I'd had some time off work for it come back to work and then because on my third day I just just didn't have it so that's so I then got in contact with the doctor and said yeah antibiotics yeah and which which she did and that's that's really sort of as in now I don't feel I've got you don't feel like you've that anymore no no fair enough alright and so it's all a bit strange isn't it you've you've got this flutter as you know you're going quite fast at the moment 100 or you certainly were when you did this ecg a couple hours ago 144 and your blood pressure is quite a bit on the low side and we started you on some tablets to try and bring the rate down which is fine but something's going on in your heart driving this fast heart rate and you're a young man you know we're committing you to lifelong tablets really with trying to control this rate I was I'll speak to the cardiology doctors I wonder whether doing a different strategy in trying to flip your heart back into the right rhythm they were they plan was is that they would put me on the bisoprolol thinners for a while yeah great and then they would eventually look at getting me in and actually into shocking my heart to get it back to what we wanted yeah exactly so how long have you been on the blood thinners I'm sorry since the may 30 fine yeah so it's been nearly 4 weeks now 4 ish weeks fine that should be you know a reasonable amount of time I'll speak to them to see whether that's within the window and they'd be able to get you over to fix it because that's gonna be the real fix you know we can tinker with your blood tinker with your bisoprolol but all it will do is drop your blood pressure further yeah so you know it's we want we need we need to be careful there with that it'd be good to make sure you haven't got a nasty pneumonia sort of question of the chest x-ray and we can have a look because your last 1 was about a month yeah I'll speak to them and see whether that's sufficient amount of time whether they'd be able to get you in to get the heart into the right rhythm a bit sooner than what they're planning given you're here with a with a quite a good rate yeah and take it from there is that okay yeah yeah great can I have a quick look at you yeah sure thank you just gonna get your hands it's hot as now know it is yeah sorry don't worry turn move forward it does sound like you got a bit of a chest infection still it's clearing can I have a look at your sore legs yeah sure if I didn't have my shoes on it would actually be the the tops of well yeah fine so I've requested your chest x-ray you can walk around and have it while you walk around and have it I'll call the cardiologist and see whether they'd be happy what their plan is about this rate and see whether they'd happy to get you over to that sound okay yeah that's fine yeah you still got some antibiotics at home which is good carrying them is good 2 days left on that course yeah with the chat on the cardiologist and the chest x-ray it'll come back immediately I'll grab you again and we'll work up with sleep that sound alright so I'll wait back out there again I'll walk you around before I show you where to go for the chest x-ray no worries any questions or anything I forgot no no no

Presenting Complaint:
Atrial flutter with persistent tachycardia despite medical therapy

Past Medical History
• Atrial flutter (May 2025)
• Sarcoidosis (2013)
• Hypertension (2010)

Diagnosis:
Atrial flutter with inadequate rate control, concurrent chest infection

I had the pleasure of meeting Scott Powell in Same Day Emergency Care today.

Mr Powell is a 35-year-old factory engineer who initially presented on 30th May 2025 with a 3-week history of chest fluttering. He was diagnosed with atrial flutter and commenced on Apixaban 5mg BD and Bisoprolol initially 2.5mg OD. On review on 6th June, his heart rate remained elevated at 144 bpm despite treatment, so his Bisoprolol was increased to 5mg OD. His BP at that time was 105/70 mmHg.

Today he presents for routine follow-up. He reports significant improvement in his fluttering symptoms and no longer experiences the racing sensation when lying down. However, he has developed bilateral ankle and foot oedema over the past 10-14 days since the Bisoprolol dose increase. He works night shifts as a factory engineer, easily achieving 10,000+ steps per shift. He has recently completed a course of Doxycycline for a chest infection which has largely resolved.

On examination today, his heart rate remains elevated at 146 bpm with hypotension (BP 90/60 mmHg). Oxygen saturations are 98% and temperature 36.9°C. He appears well, not tachypnoeic, and speaks in full sentences. There is bilateral pedal and ankle oedema present. Chest examination reveals left lower zone crepitations. No chest pain or tightness at rest, though he reports some chest tightness on walking uphill which predated his atrial flutter diagnosis.

Investigations:
Urea 8.4, Creatinine 78 (baseline 73)
NT-proBNP 1,274
INR 1.0
FBC normal
Blood gas normal apart from glucose 6.1
Chest X-ray 31/05/2025: Hilar lymphadenopathy but no signs of focal infection
ECG: Atrial flutter with ventricular rate 144 bpm
CXR 27/06/2025: Clear lung fields

Plan:
1. CXR
2. Up-titrate beta blockade as tolerated by BP
3. Add Ca, Mg, TSH +/- replace
4. Discussed with cardiology SpR Hawley
- Admit for rate control
- Uptirate with Bisoprolol 2.5mg stat
- If rate not controlled, give further Bisoprolol 2.5mg stat
- If rate remains uncontrolled following above, load with Digoxin IV 500mcg + 500mcg, then 125mcg daily from tomorrow
- Cardiology review in the morning

Summary

Investigations

Plans

Medical ST4 Miller Clerking

Presenting Complaint:
Atrial flutter with poor rate control

History of Presenting Complaint:
Patient presented with 3 weeks of palpitations and fluttering sensation in May 2025. Initially diagnosed with atrial flutter on 30th May 2025 and commenced on Apixaban and Bisoprolol. Despite up-titration of Bisoprolol from 2.5mg to 5mg daily, heart rate remains elevated at 144-147 bpm. Patient reports improvement in symptoms since starting treatment, with reduced palpitations and no racing sensation when lying down. Recently treated for chest infection with Doxycycline with good response. Reports ankle swelling and fluid retention since Bisoprolol increase.

Past Medical History:
• Atrial flutter - May 2025
• Sarcoidosis - 2013
• Central hypertension - 2010

Medication History:
• Apixaban 5mg PO BD
• Bisoprolol 5mg PO OD
• Doxycycline (recent course for chest infection)

Allergic History:
Unknown

Social History:
Works as factory engineer on night shifts. Regularly walks 10,000+ steps per shift. Lives independently. Rare alcohol consumption. Stopped drinking coffee, drinks tea regularly. Non-smoker.

On Examination:
Bilateral ankle oedema present. Chest examination suggests resolving chest infection.

Investigations:
Urea 8.4, Creatinine 78 (baseline 73), NT-proBNP 1,274, INR 1.0, FBC normal, Blood gas normal except glucose 6.1. CXR 31/05/2025: Isolated lymphadenopathy, no focal infective signs. ECG: Atrial flutter, rate 144 bpm.

Impression:
Atrial flutter with inadequate rate control despite optimal beta-blockade. Developing heart failure secondary to tachycardia.

Plan:
1. CXR [_]
2. Up-titrate beta blockade as tolerated by BP [_]
3. Add Ca, Mg, TSH +/- replace [_]
4. Discussed with cardiology SpR Hawley [_]
   - Admit for rate control [_]
   - Up-titrate with Bisoprolol 2.5mg stat [_]
   - If rate not controlled, give further Bisoprolol 2.5mg stat [_]
   - If rate remains uncontrolled following above, load with Digoxin IV 500mcg + 500mcg, then 125mcg daily from tomorrow [_]
   - Cardiology review in the morning [_]

Summary

Investigations

Plans