Pamela biffle 126118 83 year old lady so investigations bone profile normal eosinase creatinine 78 which is that patient's baseline potassium 5.7 from 4.8 on the january 22 sodium normal alt 35 previously 15 but other lfts normal and no jaundice crp of 10 note has been chronically raised and this is particularly high for patient urea 8.3 from 11.5 previously ast normal phosphate 1.63 magnesium naught 0.68 troponin 24 you need to repeat troponin full blood count hemoglobin 121 neutrophils 12.86 white cell count 18.3 arterial blood gas on presentation to the emergency department ph 7.22 with p c o 2 8.6 and base excess - 2.6 subsequent blood gas following initiation of bipap ph 7.3 with p c o 2 7.2 p o 2 8.3 and base excess - nil 0.6 had a gain medications list ventolin inhaler 1 to 2 puffs up to 4 times a day furosemide 40 mg once in the morning and once at lunchtime placing previous bumetanide started on the 10/22/2025 leuphorbec inhaler 1 to 2 puffs twice per day sertraline 100 mg once a day candesartan 4 mg once a day gtn spray 1 to 2 doses as required aspirin 75 mg once in the morning atorvastatin 40 mg in the morning lanzoprazole 30 mg the morning bisoprolol 1.25 mg in the morning and 1.25 mg in the evening famotidine 20 mg in the morning humulin m 3 kwikpen restylane libre sensor carbamer eye drops metformin 500 mg bd past medical history ckd 3 macular degeneration cataract bilateral acute nstemi may 2025 with congestive cardiac failure following sliding eye dyshernia vitreous detachment 20 24 osteoarthritis diverticulosis asthma knee osteoarthritis diverticular disease type 2 diabetes mellitus cardiac pacemaker hypertension type 2 diabetes mellitus coded 20 13 yeah you use your referral to him he says asthma pulmonary embolism 1966 she was admitted with an nstemi may 2025 which was medically managed and then subsequent decompensated heart failure with reduced ejection fraction back in may 2025 so heart failure with moderately reduced ejection fraction known to the community heart failure team p permanent pacemaker inserted for tachyprenic syndrome so on presentation at that. She had pulmonary edema a mild exacerbation of a chronic renal impairment troponin was 28 and bnp was over 1,600 had an echocardiogram which demonstrated lv ejection fraction 35 to 40% with dilated lv and mild aortic stenosis she was treated with iv diuresis dual antiplatelet therapy was suspected hence stemi is a precipitant of exacerbated lv failure so collateral from the ambulance crew called because of shortness of breath found sitting upright in an armchair in a tripod position with increased work of breathing but no audible wheeze apparently she'd been increasingly short of breath for 3 to 4 days 3 to 3 to 4 felt constantly short of breath unable to sleep due to breathlessness denied coughs sputum fever feeling unwell stated that her breathing is made worse by exertion and laying flat visited her gp last week where the gp increased the dose of her inhalers and used to be using the inhalers more frequently but they've not improved her breathlessness the ecg shows a broad complex tachycardia on presentation at a rate of a 140 consistent with a vt but could also be consistent with an af with a bundle branch block currently rate is 90 beats per minute with a broad complex tachycardia on the monitor and but clear p wave seen on the monitor so needs a repeat 12 lead ecg note her tep form which has been discussed by the gp for ward based care only not for cpr or itu which I agree with she's allergic to macrolides apparently allergic to prednisolone and allergic to statins hello is it pamela hi I'm rob I'm 1 of the medical doctors pleasure to meet you how are you a little better they've made you feel better I'm glad yeah yeah they're very good at that the team here have been looking after you ever so well I'm glad to hear they've made you feel better I hear your breathing's been difficult for the last few days is that right and what's been going on with that why is that do you think I've heard a little bit of a sudden I've been in and out since here mhmm most of the last year with the heart attack mhmm and you couldn't breathe at that time as well I think this has started this year there was a go and I I went right through so I've been asked to go see her mhmm she was a bit scanty sounds scary yeah but you're in the right place now and having some good treatment to get you feeling better very it's a pleasure it's not me it's the e a and e team of dull and warfarin yeah I've got awful headache yeah awful headache mhmm the high level of carbon dioxide in your blood is because you weren't breathing enough because of this problem with the heart and lungs that makes give you a terrible headache but as we wash it out you'll get better and we can give you some painkillers for it in the meantime I can't give you anything too strong because I don't wanna affect your breathing too much so maybe grin and bear it for a little bit we can definitely get you something like paracetamol for alright not all I understand that you live at home with your husband is that right with your partner I should say sorry and are they well your partner oh yeah he's a as a fiddle he's a bit as a fiddle very good fine just as well yes that's good and how are you how do you manage at home well I can't do a lot what kind of things can you do it's because of the arthritis so I have to walk every day with a walker a 3 wheeled walker 4 wheeled walker 3 wheeled 3 wheeled walker mhmm and it takes a lot of swimming mhmm and is that your breathing or is is it just your arthritis both bit of both how far can you walk on the flat not very far it's not how much how often do you get out of the house twice a week twice a week very good what kind of things do you get up to so I go to church and come in there of course and see my daughter this day then I'm sorry should I get you something for it before we keep chatting of course sorry thank you don't worry and it's making like people ask as well mhmm it's horrible stuff I know this mask is horrid so on a map of 7 cm of water fio2 25% pulse rate 97 sat's 97% respiratory rate 21 blood pressure 130 over 80 hi pam I just need to take a nasty blood test from your wrist is that okay just to see how this mask is doing I know it's not very nice but I'll give you a bit of local anesthetic for it just a clean test and I'll just rest your arm maybe I can put the pillow there and rest your arm like that is that nice what's other stuff I need a bleeding and just put a bit of local anesthetic okay you're actually healing sorry can you double that very well jess jess I think you did up to me yep is that right I don't know I think it's not gonna work yeah that's pretty it's too early it's not really you're right I I don't think it's too early at the moment isn't it yeah I think it's working do you want another keto every day no do we have a fever that you have tea days they asked you on this morning this afternoon so okay yeah we'll just do that morning just a minute okay quiet heart cells where's your pacemaker then on the other side it's up there and then it slips down can you feel it it's okay can I see your tongue thank you that's fine can you look down to that corner of the room for me that's lovely thank you we'll get you a bit more water medicine to get some of this fluid off do you want me to call your husband and or your sorry your partner and let them know what's going on yeah alright you're happy for me to tell them everything say again yeah we can let you go to the toilet it's gonna be challenging with this mask we may need to help you with a bedpan chest x-ray demonstrating bilateral perihilar infiltrates representing pulmonary edema but infection within the differential abg is demonstrating continual improvement on bipap with ph improving to 7.36 and pco 2 6.4 therefore to switch to cpap and if stability on this for admission to ccu discussed with cardiology consultant doctor felmeden who yeah agrees that she could be admitted to ccu most recent echocardiogram reviewed back in may 2025 which demonstrated heart failure with a reduced ejection fraction yeah you don't keep any of bed spaces either do you the most recent echocardiogram was in may 2025 demonstrating ef 35 to 40% impaired lv systolic function mild mr and tr intermediate probability of pulmonary hypertension and mild aortic stenosis in low flow state biatrial dilatation the impo a hint of the impression is I'll have a look this later on so going back it looks like she started on furosemide in october 2025 and previously she was taking bumetanide so impression is decompensated ccf either due to missed myocardial infarction however no chest pain which goes against previous presentations with acs where she did have chest pain versus switch from furosemide to bumetanide requiring bipap for type 2 respiratory failure initially likely due to significant tiring in the context of respiratory compromise from heart failure plan now that acidosis has resolved with bipap for switch to cpap and regas in 1 hour's time if remains if remains stable or improved on cpap for transfer to ccu for management there I've discussed with doctor flemingen who's happy for this to occur repeat ecg 80 iv bd of furosemide nitrates to aid fluid mobilization repeat abg 1 hour after starting cpap discuss with husband regarding admission I agree with the chat forms that can stay for ward based care only sealing of care being cpap so that's the plan nurse in bed to allow him I just saw my dinitrate infusion wean cpap as able once oxygenation improved following further diuresis further episode further docephirizamide this afternoon however haven't weaned the the cpap this afternoon as she was in significant type 2 respiratory failure on presentation I'm concerned that this is recurring it may be safe to keep her on cpap overnight and aim to wean tomorrow following further diuresis