Next patient julian clay 229939 80 year old lady investigations tsh 5.32 t 4 awaited he's normal creatinine 81 at patient's baseline potassium normal lfts normal crp 1 urea normal ast normal magnesium normal troponin t3 t 13 full blood count normal fbbbg ph 7.37 basic says 3.4 note admission with possible melina november 2025 she had 1 episode of lower abdominal pain on the november 20 and 1 episode of melina on the subsequent day pr didn't demonstrate any evidence of melina and he biochemically wasn't supportive of gi bleeding she was reviewed subsequently in a second discharge as and there was no further melina other medical history atrial fibrillation 2020 laparoscopic cholecystectomy 2020 hypertension ckd 3 medications list c a t I o l a n z e eyedrops 1 drop to both eyes at night busoprolol 5 mg once a day pixaban 5 mg twice a day meprazole 10 mg once a day cinnarizine 15 mg tablets 3 times a day as required lisinopril 10 mg tablets once per day most recent echocardiogram 2020 normal systolic function ejection fraction 50% mild anterior leaflet thickening no prolapse mild to moderate mitral valve regurgitation 8 ecg with the cardiology team in may 2024 demonstrated sinus rhythm at that time add to investigations list chest x-ray clear lung fields bilaterally possibly slightly increased okay I've got that I'm just thinking about that thinking I'm looking for you exactly thanks mate and if can just take it from my phone if you want to 106 a 117 a 119 we're winning slowly aren't we yeah I'm just I don't know if you realize I've just taken which a young lady that when I was a nurse mhmm I took my medication for the morning mhmm without it mike where's the piece of paper that I I can pick it up on computer on a thursday well they couldn't find it earlier oh really I I do a prescription for it brought my sheet that I got yesterday I didn't use so much I've got I've got I've got it on my nhs site alright that's the medicine so as you say 10 mg a month yes but don't forget the bisoprolol I only take half that amount yeah fine it's a very good 1 because at any day I might need to put it back and today might be that day yeah yeah fair enough good to have it in your back pocket yeah what do you do with your half filled with the softener well I throw the other half away I don't keep it for a rainy day no I don't keep it for the next day alright interesting it's a shame right it is felt maybe I did yeah yeah clotting I don't we know try to be healthy we try to acknowledge but day the day then we're on and then okay you might see from my notes I was only here at about 3 weeks ago and I thought I had a bowel bleed I didn't see no and I don't think I had that yes you had a dark stool it's like your blood tests look fine and then you came back the next day everything was fine and then I came back the following I was crying yeah came back on the phone I actually felt a little embarrassed at 10 actually I had that saw that afterwards yours was slightly dark and quiet okay but it was quite that's and when I say to anybody they say you've been I say I always look after her and check check you seem very well rest I think if you stay too much longer you might have a job I would like that did work for a little while in a nursing home I wasn't a nurse but I was an nurse but I did work there quite a lot and my parents were admitted with infection oh were they so lots yes of talk and messing around with you there was there was and that was quite a bit of a yeah and then you're asking just straw technique over a couple of minutes just after the nuts you said that was great so just don't do it I know sorry just relax yeah fine I don't know I guess the question is shall we just change tacks here you've had 10 years of bisoprolol you're still going fast you're not really managing the bisoprolol anyway in I don't like it which obviously is quite convicting so we're unlikely to get you off it I think it will it work all night with the lisinopril that'll be fine with the pills and the apixaban yeah they'll be fine with those 2 yeah shouldn't be any problem I might stop these while we're drinking the best that's that's the worst 1 it's all I'll stop them now and and hair thinning I've lost so much air I don't know about that not on digoxin if I have do you think that make it worse no the hair I don't know don't know don't know that's the side effects the joxin but the consultant coming around in half an hour is the world expert on the joxin drug so he might tell you some of by how doctor paul andrews he's cardiologist a who runs the acute medical consultant no nobody other than yourself no no you've done really well alright yes and do I was just halfway through examining yourself yeah my hands listening to you I was feeling your pulse I was looking at the amount of fluid you've got in there lovely but the fingers do go black and so do the feet but it's cold all the time all the time when I'm sitting I look down and they go white dark white dark as soon as I start walking it clears things I don't take to the doctor and especially how far down the finger does it go all the way down or is it just the tips no tips I would say or the foot there is some loss of sensitivity in some of my toes but it's almost like the skin and I can't feel it properly but the skin gone hard and the skin has gone harder yeah so it could well be could well be that these are just little things that I can throw in have a throw them in I like it have a quick listen to your heart oh just take let's go ahead and think can I a bone go through back in here back in here oh yeah that's a good bit to think take a big breath in and breath all the way out and stop there can I have a listen to your back as I move big breath whenever you're ready okay just moment a yes looks good let's go back to the room and I've had that over a few years and I cause wriggly pains across my chest which don't settle into anything sorry sorry I've been painful in my legs there's so much fluid there you're not really elicited a huge amount of fluid there is a leakage there is there is but they know that ablation sorry that's okay you can just go to the nearest care stops there does it a little bit of a heart murmur stick it on the outside but not on the inside brilliant so just to give you some more okay obviously the heart beating in a regular way or in a more controlled way or rate to control does improve its function the atria can't fill well when it's this fast so an element of the problem with the heart and the blue belly on the right is actually triggered you've got atrial fibrillation that could be to do with the bisoprolol or the lisinopril couldn't it it certainly could be it certainly could be the bisoprolol if your rate's going at 50 it's not enough is it no and that could cause yeah phytic cleaning in itself yes yes well that's usually when I'm sleeping not in the it was when I was really lightheaded yeah mhmm but I did phone the doctor then and I did cut it back and that's why I thought I'll cut it back again because I felt it needed it so we've got a plan should we switch you to the digoxin yes for sure for sure spoken to it was that the gentleman I went to see there well I don't think no no no no no so should I speak to the doctor the specialist yeah yeah hopefully not if I don't agree but let's go with another and and see if he agrees with you sounds good before I go down that route and we've done it sounds good yeah and it'll give a bit more time for the bisoprolol to work as well yeah lovely I don't think we need to change anything else this fluid I don't think it's doing very much to honest with you it's not really any more fluid but you've got sometimes I find that stretch can make the heart go ahead so that it's it's not an unreasonable thing to do really say stretch yeah stretching the atria slightly yeah with with a bit of fluid that's probably good for all of you today yeah if you've got atrial fibrillation I'd say was I dehydrated I don't take a dehydrated I've been blood tested too do no no but again I can see why the only doctor put you on it because sometimes the irregular circuit travels around your mitral valve it's a circuit that's formed probably lots of people have but for some people it's active and for some people not so it's spiralling round the mitral valve causing this irregular heartbeat and sometimes stretching the mitral valve out with a bit of fluid can break that cycle I think I came in early last year and it went back and that's not the? It was feeling that I was concerned mhmm but I guess I had the cold water yeah yeah I don't need the cold water go and find a consultant I'm looking for it if you can yeah yeah I don't I can't promise this if because every day covers patients different no but either way there'll be a medical consultant in 10 minutes if there's somebody who of discuss that way forward sounds good I'll be back here long and you know for how long with the digoxin well that would be forever just like the bisoprolol I'm never going to come off it have come off 2 and a half of lisinopril I am on a so oesophageal drop your blood pressure yes is kind of beautiful I am am on a right right oh that's so well so able to see that yeah what's the trial reducing her blood pressure I've come off 2 and a half lisinopril and that was last january really no no give it to me the the pink thing the pink the pink thing that I have to carry in my back because of apixaban you've removed it should be in the back no it should be where the zip is oh at the back that's why it should be in the bag so you're 2 of those and now I know where these things are just 1 compartment is enough isn't it yeah I've just got a pocket in no this should be all on its own it shouldn't be with other things that ladies carry with them so that's a pixaban and that's emergency monitoring this is for the trial yes it's 1 way to know they'd want to know if you were here to be optimised too it's the person I saw I will let your doctor know because yeah you should they should know as part of the trial yeah that's what it puts it on thank you I'm optimised too alright that's it alright great I'll come around in a little bit palpations and chest discomfort today problems with using bisoprolol leading to bradycardia that she notices on her watch and has since has cut the dose down to 2.5 mg despite being prescribed 5 mg in an attempt to combat this but still experiences episodes of bradycardia and also intermittent episodes of lightheadedness which she attributes to bradycardia secondary to bisoprolol current rate a 120 to a 125 beats per minute she's had 2.5 of bisoprolol then a further 2.5 of bisoprolol by herself the evening before she came in then 5 then 2.5 of bisoprolol this morning despite that the rate remains uncontrolled impression atrial fibrillation with a fast ventricular response without clear underlying trigger given reassuring bloods and chest x-ray as well as urine suggest or plan give a bit more time for the bisoprolol to work but given problems with bisoprolol suggest switching to digoxin and I've briefly discussed the role of digoxin here which patient would be happy to go on if consultant agrees this morning on post op ward round once rate controlled home for rate control strategy given structural heart disease on echocardiogram demonstrating mitral valve regurgitation previously