Transcription - 20250804T 06-41.mp3

Next patient is margaret liverrette alpha268987 86 year old lady investigations ct head no intra extra or collectional hemorrhage no mass effector acute irritable infarct diffuse supernatrophy consistent with the patient's age chronic lacunar infarcts bilaterally in the basal ganglia ventricles and basal systems unremarkable crp 6 sodium a 148 creatinine 101 alp a 144 troponin 4 full blood count normal inr normal radin baseline a hundred and hundred note alp has been high previously hello robert yeah hi I'm rob I'm 1 of the medical registrars nice to meet you I've been happy yeah have you yeah I've what have you been seeing anything good you're busy no not me not not too busy yeah yeah how are you a lot better than me good I'm glad glad I noticed down very nicely yeah you had the medicine the doxazosin which took some time to work but when it did work it worked really well no I'm on no right as we get older we get high blood pressure and we know that well I've had it you have well not you had some recent investigations and the scan of your heart was quite reassuring and the tape of your heart which looked at the way the heart was beating was reassuring as well so that's noticed your legs swelling up I think they that's that's it it ends in zed I n doc's has sent it yeah okay and but the names and that are keeping them I thought the amlodipine caused your legs to swell up no well I don't know they might have said that but but the other 1 did almost over and how are they are they more swollen at the moment than normal they are a bit yeah they're sorry yeah they're very great with having some water medicine to get them off couldn't you it doesn't look like you're on any water medicine they don't that will bring you fruit and fruit does it not in what way no it doesn't make me ill mhmm the toilet yeah you've got edema up to your knees swelling up to your knees you've a good amount of fluid I know I have to come off and that will bring not to the. But that will bring your blood pressure down if you can't remove the fluid if you've got too much fluid circulating that can make the blood pressure high does that make sense if you've got lots of fluid through a pipe the pressure in the pipe will be high they did tell me that I've got a little bit at the bottom of the exactly you do yeah they told me that after my lid so you've certainly got a bit too much lose weight and I'm eating biscuits ah well I love biscuits but you know it's not that kind of weight that you need to lose really it's the flu is awake it's the best weight loss programme we've got you've probably got a kilo in each leg at least I would think of fluid it feels like your legs would feel like 1 is numb yeah really that leg is numb I've been sitting on it when did you first notice that the numb leg about 6 months it started going down today but I just hardly walked mhmm alright and now all that's gone all good pain's gone it's all it's all up and cushing now well it's a good take gonna have a quick listen to your heart do you mind no that's alright thank you that's fine give me just a quick listen to your can you bear take anything off and I'll listen to you here breath whenever you're ready I've got some fluid on your lungs you've got the fascias on both your bases yeah any pain in your tummy at all no no that's good great and you've got swelling I'll just poke up here if that's okay yeah your hips really haven't you swelling yeah half life didn't it I think you feel a lot better with this fluid up even if you were rushing to the toilet for the first few weeks if we got the fluid off your lungs would be less full of water you'd be able to work walk further because your legs would be less yeah I get heavy and your blood pressure would be better when I'm walking yeah well I bet you do I've got that would be my suggestion you're that you're saying they're not the ones that make your legs swell up they're not like those they bring your legs down I think it'll work really well for you to make you feel better and that's what's causing your blood pressure in the eye we can treat the symptoms by bringing your blood pressure down with tablets or we can treat the cause which is having too much fluid and get rid of the fluid do you know what I mean I don't mind which we do but if I were you I think taking the fluid off will give you benefits over and above just controlling the blood pressure oh you get really good routine to go back yeah I've got to do something good so what are you allergic to again I don't know a beta blocker yeah okay years okay fine and who do you live with at home my partner it's about a year we've been together now lovely oh it's like starting a new life again so I better get my name sorted out exactly yeah is it your age or have you got a toy boy age or have bus assisted passage brilliant lovely we've treatment we've been in going up even higher it's just a lids group in the lab well you might love it too much and at the beach yeah he's on the beach and he's coming home oh I don't know if he'll ever come home right on the beach like that it'll be fantastic she says and the sea you can see it coming up towards you and when it's really loud whether good yeah sprays the the windows upstairs windows it'd be good because there'll be no midgies with the the sea breeze lovely wouldn't it it'd be really nice how do you get around the house do you walk with a stick or frame or just your own legs no I have got a stick but I walk without the stick most of the time you use it without the stick walking but I don't great so you've got a stick you walk ride a frame mhmm walking use a frame outside yeah a 3 wheeled walker with a little basket on the front so a seat with a seat yeah 3 wheeled walker great yeah for a living my partner does the same thing they get you out to it your blood pressure's better now and yeah I was fortunate mhmm great did he like playing yeah I guess that was lucky and what did you do for a living what do I do what did you do what did I do he was a sailor was he okay he was in drink or smoke oh you ever smoked before no never had any problem and I everyone isn't it yeah but I mean yeah we couldn't understand what had happened he sat in the back of the car when he got a go like that to him he's saying he gonna what hit me boring I meant to say we cut him obviously being in here is a scary not place gonna isn't it mad at me I keep trying but I'm sure he'll it worked it worked on me you just gotta keep pushing ask my wife she'll tell you yeah once and then we don't think like that and we're just I know he's we're focused on the present too much I don't no need jesus exactly I that's not very romantic is it no I figured we'd just read that he bought me a thread of ring mhmm that's a clever 1 I'm sure he'll get that yeah he thinks exactly yeah you'll break him don't worry he's got his stomach no no no one's that stomach I'm sure he can't resist your chance I couldn't wish for a better person I meant to say obviously it's scary being in hospital scary being here obviously we've had some drama tonight yes we're done but I hope you're okay I'm fine good that's fine alright that's fine that's all 06:00 good I'm glad alright but I'm saying well this is a much nicer environment yeah I think that would be a good idea I think we'll feel better I really do I think you'll I mean once you show him your knee's thin ankles there's no way he won't get down on 1 move well he called he called me his sunshine believe it or not oh that's lovely because I'm always smiling and laughing brilliant yeah I like your voice oh really spinning that's serious isn't it what is it about 5 great yeah yeah he sounds great yeah about 2 years now exactly went to the doctor's last week mhmm and we both went to the doctor's present there you great yeah so 2 years ago well I'll go and get those things sorted for you I've changed the doc's access in to the furosemide to try and get them in your truck do you think I'll try and get out of here today can I get you out of here today yeah if that's okay appointment at the doctor's your blood pressure's better we'll get you on some furosemide and we'll take it from there that sound okay I think we should be able to get you out of your skin it does yeah yeah it's good lovely to meet you thank you hear about your life and family thank you yeah thank you your biscuit you want it back yeah it's a little bit yeah it's your cup of tea yeah do you want the biscuit thank you k yeah I'll bring it forward for you I won't touch it yeah because I've just jumped my hands it'll smell like alcohol so impression is accelerated hypertension secondary to overload secondary to heart failure with preserved ejection fraction plan number 1 stop the excesses start furosemide number 2 aim home today with early gp follow-up to recheck the usernese middle of next week and consider escalation of furosemide

Medical ST4 Miller Clerking

Presenting Complaint:
Hypertension

History of Presenting Complaint:
This 86-year-old lady presented generally unwell, lightheaded, weak, possible right-sided facial droop. This resolved at the time of assessment. She has been experiencing bilateral leg swelling up to her knees for several months, which has been progressively worsening.
The swelling is particularly noticeable and causes her legs to feel heavy when walking. The patient feels that her mobility has been affected by the heavy sensation in her legs.

She denies any chest pain or acute shortness of breath but acknowledges feeling more limited in her walking distance.

Recent admission with accelerated hypertension, managed with doxazocin. Recently stopped by GP after reports of morning nausea.

ACEi have led to leg swelling.

Past Medical History:
• Hypertension (February 2025)
• Heart failure with preserved ejection fraction
• Ischaemic heart disease (2003)
• Previous coronary angioplasty (2003)
• Chronic kidney disease stage 3 (2015)
• Age-related macular degeneration - both eyes
• Bilateral cataracts - surgically treated (2024)
• Left hip osteoarthritis (June 2023)
• Gastro-oesophageal reflux disease (June 2023)
• Vitamin B12 deficiency (2018)
• Anaemia (April 2020)
• Previous total abdominal hysterectomy (1975)
• Previous emergency appendicectomy (1979)

Drug History:
• Losartan 50mg PO OD
• Simvastatin 20mg PO ON
• Omeprazole 20mg PO OD
• Cyanocobalamin 50mcg PO BD
• Ferrous sulfate 200mg PO OD
• Glyceryl trinitrate 400mcg sublingual spray PRN
• Pregabalin 100mg PO ON
• Diclofenac diethylammonium 2.32% gel BD topically
• Epimax original cream PRN
• Medi Derma-S barrier cream BD topically

Social History:
Lives with partner of approximately one year. Uses walking stick but often walks without it indoors. Uses 3-wheeled walker with seat outdoors. Partner provides support with daily activities. Never smoked. Independent with most activities but limited by leg swelling and heaviness.

On Examination:
General Appearance: Alert, well-appearing elderly lady, comfortable at rest
Observations: Initial BP 234/82 mmHg, HR 76/min, RR 20/min, O2 sats 96% on air, Temp 36.9°C
Post-doxazosin: BP 147/67 mmHg, HR 64/min
• Cardiovascular: Bilateral basal crepitations
• Extremities: Significant bilateral leg oedema extending to hips
• Abdomen: Soft and non-tender
• Neurology: No limb weakness or facial droop.

Investigations:
• CT Head: No intra or extra-axial haemorrhage, no mass effect or acute infarct, diffuse cerebral atrophy consistent with age, chronic lacunar infarcts bilaterally in basal ganglia
• CRP: 6
• Sodium: 148
• Creatinine: 101
• ALP: 144 (previously elevated)
• Troponin: 4
• Full blood count: normal
• INR: normal
• TTE (24/02/2025): Normal LV size with preserved systolic function (EF 55-60%), mildly dilated RV with reasonable function, mild AS, trace AR
• 24h Holter (March 2025): Sinus rhythm with infrequent sinus tachycardia, first degree AV block throughout
• CXR:

Impression:
Transient neurological symptoms
secondary to hypertensive encephalopathy
secondary to accelerated hypertension
secondary to fluid overload
secondary to heart failure with preserved ejection fraction
Raised ALP secondary to above

Management Plan:
1. commence furosemide for diuresis
2. Aim for discharge home today with virtual ward follow-up to recheck UE, BP, weights and consider cessation of doxazosin once diuresis achieved
3. Consider escalation of furosemide dose if inadequate diuresis or switch to bumetanide
4. CXR [/]

Summary

Investigations

Plans