The next patient tracy reynolds 513643 born on the 02/12/1965 you can work out her age past medical history hypertension issue mitral valve repair 1984 mitral valve replacement 2024 asthma uses inhalers reviews gallstones medications is candesartan 4 mg in the morning spironolactone 25 mg in the morning salbutamol 100 micrograms inhaler is required dapagliflozin 10 mg once in the morning atorvastatin 20 mg at night bisoprolol 1.25 mg in the morning fostair nexthaler 100 micrograms inhaled once per day past medical history a v s d 19 84 tissue mitral valve repair 20 24 november hypertension and asthma admitted today for elective surgery planned for total abdominal hysterectomy and bilateral salpingo oophorectomy went to the anesthetic room blood pressure was 230 over 80 both noninvasively and with arterial blood pressure investigations observations blood pressure a 180 to 200 over 60 to 70 sats 9096% respirations 18 on air alert no pulse recorded observations in theater a 175 to a 184 over 66 to 74 with normal pulse rate temperature and respirations investigations blood tests today creatinine 60 cholesterol and triglycerides are normal full blood count normal glucose normal ggts mildly raised at 40 tsh normal notes mentioned ecg undertaken however not identified in the notes currently I've done it you've had have you ever had a read about everything and you came in yes obviously gap yeah to the surgery today and then your blood pressure was quite high yeah it's yeah it was quite high yeah yeah but you did you feel fine during when your blood pressure was high yeah I have noticed that all I I didn't notice that but think you have my is where you so your blood in your ear yes like rushing yes yeah mhmm yeah okay so I think that was probably that's something I should take notes of any headaches no visual changes not now because my glasses have changed probably years anyway so no I could I wouldn't have leg swelling sorry I have noticed a little bit of leg because it was reduced immensely after I had my surgery I was on for really mine for about 6 weeks then it all stopped and my ankles went down dramatically but I have noticed a bit of swelling in the last couple couple of of weeks weeks mhmm and you've got high blood pressure yes you take candesartan yes I do yeah and did you have it today yes yeah I have it small that's good 4 mg tablets I took it there yeah yeah I had I a saw that yeah fine it may be that you just need a slightly higher dose yeah and that's what the anesthetist said it might be that they need to put it might just be for a little while but it might be not as bad yeah obviously you come over to our medical ward yes for us to just keep an eye on your blood pressure I don't think your blood pressure's been quite good really while you've been here certainly not as high as it was in the anesthetic room but it was very high yeah it did go scarily high yeah for sure and obviously it's a worrying environment for everyone because they don't wanna put you to sleep because things can get a bit worse think what's helped in this scenario I should might well have read big 1 on since last year and it all got stopped because of my tummy yeah yeah because they had to deal with my heart first so that was dealt with so this been has a long time coming and then last week we got we that we'd be moving next wednesday oh god yeah fine so that's added to the yeah so many stressful things all at once yeah and and I think by wednesday afternoon I I've more or less had enough mhmm and I I I said to my boss I'm gonna I'm having a quick night yesterday so that's all I did you knew I wouldn't be in today yeah that's right and I've taken the week off next as well what do you do for a living it's a desk job I work in a construction company right but you know the job my job isn't stressful okay and I have worked in stressful environments because I do payroll got it a doc yard and I've worked in a care company mhmm so you know what it can be like yeah mhmm so I've never let my job affect me yeah mhmm so this is all to do with what's going on at home yeah yeah yeah course yeah of course fine so we've got a reason that you might be having these high blood pressure and also your blood you've got high blood pressure anyway so we know that as time goes on those doses can need to go up a little bit especially when all this other stuff going on and also your heart's beating better now you've had the mitral valve replacement so that can contribute to high blood pressure as well so all those things together are probably the cause of it the important thing we need to work out is whether you there's any damage from this high blood pressure on any of your organs from the look of your blood test they look fine perfect so I'll just hope to have a listen to your chest just to make sure you haven't got any fluid on your lungs building up and then the tracing of your heart it looks like you had 1 in in the anesthetic department yes I did but I can't see it I don't know where it's gone because it's not in the nose actually no they've done it made my eye better they tried to do 1 okay and it didn't work fine okay they couldn't get the machine to work fine so she said that's they're gonna leave it it might you go into recovery yeah and do that recovery fine okay yeah so was a 1 done we could do that now if you don't mind fine get any gcm just to make sure there's no problem with your heart but you're getting any sleep in here tonight is probably not gonna happen every night well it's not it's it's just the environment you know mhmm I'm used to being awake 3 or 4 times a night okay my bladder yeah yeah fine okay I think that's a bit to do with the pressure of that down there I'm gonna leave you alone also causing the mental health doesn't it so it definitely doesn't help I mean like I see your blood pressure's not too bad now if you wanted you could go home now if you wanted or you could have a bit of a dose of some blood pressure medicine and go home and come back but I tend not to send people home at midnight I don't so just stay in hospital and we'll sort all that out in the morning right okay just and I'm I'm more than happy with that but if you're incredibly keen to get out of here and go home to sleep then I'm sure we could facilitate that if you wanted because your because your blood pressure has been not nearly as high as you always have been and all I'm gonna do is give you another dose of candesartan probably another 2 mg of candesartan tell you to increase your dose and then try and bring your blood pressure down slowly over the course of weeks with your gp because dropping it down quickly in hospital is not the right thing for you no wouldn't have thought so it's all about those slow changes and yeah I think we're gonna have to leave it because my husband's got to get up early in the morning for work he's probably sound on now so getting him awake it's alright good that's fine so we'll I'll give you a dose of candesartan yeah and we'll keep an eye on your blood pressure in the morning yeah and hopefully we'll get you out of here tomorrow all being well as long as your blood pressure hasn't spiked up at all or anything like that and then I'll increase your dose of candesartan and ask your gp to increase the dose for you so bring it up to 6 yeah if you take 4 4 mg tablets is that 1 tablet of 4 1 tablet every morning so we need to provide you with some twos to bring it up to 6 so we can do that and then keep an eye on your have you got a blood pressure machine at home yes I have great so you can take a little diary a couple of times a day okay and book a gp appointment in a week's time with those results and if it's still high at home then you can increase it again and go up to 8 alright okay if not you can either sound alright yes it does cool can I have a quick look at your social media I think it's gonna be a nice start with thank you yes yeah yeah they tried on that side oh did they perhaps yeah and it didn't work alright that 1 collapsed because I've already had 1 in that side so that 1 there they've done that 1 a little bit itchy up there and I think I'm gonna have a I think it was a bleeding actually yeah big bruise underneath would you mind sitting for I can listen to your back and keep looking up on your lungs I agree I've got some swelling in your legs yeah yeah which goes up to your knees yes on both sides yeah I don't feel quite an infection in them you have got some kind of chronic venous changes that go with having swollen legs much with yeah you may have had swollen legs for some time yes I did I did do you want any freeze at all at the moment no nothing at all it's up to you I mean you could try going back on a low dose I think might be a good idea we know that you know with the more time that you spend with the heart that's where the valve isn't so fantastic the heart remodels it changes shape the way that it beeps changes and then when we rush in and change the mitral valve suddenly it needs to adjust again and it's beating in a way to try and push through a stiffened mitral valve that's had a mitral valve repair and then you and then now you've got a brand new fresh mitral valve it needs to be in a different way so it may be that your heart needs to adjust and for that? You need a bit of bruised mitral to wash things out yeah like I said I had it for 6 weeks after I might be 4 weeks on a yeah then they reduced it to $1.85 yeah yeah it'd be great to get you off it wouldn't it because your heart should be beating in a way that you don't need it yeah but it may be for this bit of time you just need 20 mg I was gonna say it it is yeah yeah you'll feel better you'll able to walk better yeah and I did get because I've I've been before I had my operation I got used to having canes rather than ankles and when it did finally go down after taking the cruise ride so I wake up in the morning and go to bed at which I didn't remember before someone sent it to me oh yeah because obviously they mentioned it to him and when I was when I was discharged I asked if they could let me know what it was she said the nurse told me that they sent the test off to bristol she said anyway when I seen louisa in january for my checkup she was absolutely with the way I was going okay but and I and I mentioned it again and she looked through my notes she said there is nothing down here within your anesthetic she said but there is a mention that when you got back swollen tongue and a rash on your chest well said so she obviously pushed it a bit further mentioned it again so I have kept it going all along then I finally got some allergy checking my blood back up again of course to go have because all in that machine it's like water very thin exactly yeah yeah fine you won't give me any of that anymore no no and that's it he said the chances of you having to have that again I know we would have done today but obviously we didn't so yeah but we get once you've got yeah no I I completely understand the of 100% yeah I'm I'm you know more than happy the fact that my family are no 1 ecstatic yeah yeah but you know I yeah well nice to meet you and you too see you later yep I'll tell you why off so you can place it on I'll try to use it number yeah 1 ecg number 2 chest x-ray number 3 start days of candesartan number 4 increase candesartan to 6 mg once per day with gp follow-up in a week's time number 5 patient should take blood pressure diary over the week and discuss with gp number 6 rebook appointment once blood pressure controlled rebook operation once blood pressure controlled