So it's margaret 9 67915 margaret andrucci andrucci hague a n d r u c c I - h a I d 78 year old lady current repeat repeat medication visoprolol 1.25 mg once a day lisinopril 2.5 mg once a day past medical history cardiomyopathy with left bundle branch block diagnosed february 2025 hysterectomy 1995 anxiety and depression most recent echocardiogram january 2025 impaired bordering severely impaired lv function in the presence of tachycardia impaired diastolic function with elevated filling pressures at rest regional wall motion abnormalities demonstrated moderately dilated lv with normal lv wall thickness high probability of pulmonary hypertension moderate mitral regurgitation at least mild tricuspid regurgitation mild degree of aortic regurgitation good myocardial contractility in the mid basal anterior and mid basal lateral wall but all remaining wall regions are virtually akinetic I've seen cardiology she was asymptomatic at that time sustained alcohol intake of 1 bottle of wine a day she underwent ct coronary angiography she was undertaken on the 2025 no obstructive coronary artery disease and then went back to see cardiology or spoke on the telephone very good heart for a lady in her seventies left bundle can be a normal variant with age in their letter they describe the echocardiogram as normal but clearly is not so unclear if that was overlooked investigations today full blood count white cells 14.8 neutrophils 12.92 hemoglobin a 147 arterial blood gas pco2 6.6 ph 7.22 p o 2 10.5 glucose 14.4 lactate 3.9 and base excess - 7.9 nt probnp 17,105 venous blood gas ph 7.14 with lactate 6.2 on presentation coagulation screen normal blood is negative so far using his normal lfts demonstrating alt 94 and alp 138 with normal bilirubin crp 3 urea 5.6 ast 162 covid pcr negative so observations heart rate 85 so that's a 100% blood pressure 171 over 84 strict 10 so you're breathing and stuff until you cut over yeah of course can I have a quick listen to your back is that alright yeah you don't have to be a mega looking for it I find it we just want to have a look at your heart which is obviously in your chest can I take your gown down is that okay are you done up at the back obviously you're going to see some here so so when did all this shortness of breath start did it start suddenly or more gradually suddenly suddenly really what were you doing when it came on very thankful your arm out yeah painless so far gonna pop your arm out of there I was like sitting watching telly last time yeah it went downhill from there mhmm so you just sat watching telly and then suddenly you felt very short of breath yeah and did you have any pain in your chest when you when you had that shortness of breath no nothing like that and when did you see the cardiologist and get taken off the medication I would take probably more than new york fine sorry about the throat jenny so the cardiologist and you and then you stop the message because that was because you're essentially coordinating down the office and the credits are good yeah a busy I'm gonna put you on he's the used phone to it necessarily yeah okay alright anything changes just let us know mhmm and but don't think we're gonna on the hour think you're gonna be side pretty hyperkinetic globally mhmm not a huge amount of mind cardiac which is the uk does it feel better to sit for her fine to sit for her get lovely views look at that lv okay it always is okay so let's get you on some cpap because clearly the heart is the problem must be some aortic stenosis isn't it feel free to carry on if you'd like oh no no yeah good I've seen what I need to see your heart doesn't move fantastically and your chest x-ray looks like your heart's not moving fantastically either not moving enough or slipping we need to get you on a tight fitting mask to help you breathe and we'll set that up for you now to get enough oxygen in to help you clear the carbon dioxide that's building up we need to get you on a drip of some medicine called nitrate which helps dilate the blood vessels to help you clear the fluid and we need to get you on a bit more water medicine to help you weave things out you're quite poorly with this yeah yeah you need to stay in bed and you'll be continually nursed in bed so I suggest we've got a catheter in mhmm because you'll need to pass urine somehow is that alright yep good we'll get all these things sorted now they'll come sat with cpap to get you feeling better and then we can have a prop check okay okay so on examination cause crepitations to the midzones heart sounds normal anteriorly thin and cachectic abdomen soft and nontender bilateral crepitations to the mid zones right corsa no sorry left corsa then right there's donkey's here there's donkey's here yeah alright there you go and you live in a house or a flat on the line we live in a rented house in the lovely bloody have a lovely lovely irish family lovely it sounds lovely and what do you guys do for fun do you get out on the moor much do you go walking we walk a lot we have an allotment which keeps us busy and fit lovely that's good robin does 3 or 4 miles a day walking mhmm yep we do bird watching you name it do it great we're we're outdoors people yeah lovely that sounds nice and how about smoking you smoke nope drink alcohol robin robin likes a jar yep how much is the jar I I a couple of shots all night mhmm a boy yeah fine but how long have you done that for she's always had a problem sleeping so the wife I see helps with that sleeping yeah of course how long have you done that for robin the drinking long time yes sometimes the alcohol can affect the heart and certainly the echocardiogram that I just had a look at your your heart it looked as though that's a possibility but we can have another look at it ready for this blood test yeah that's fine so when did you last have something to drink before you came into hospital last night for example last evening last yesterday evening yeah yeah excellent have you ever withdrawn from alcohol before no ever needed to drink in the morning when you woke up no no let me take another little blood test while I'm here you're relieving 've just sold for the holes sorry there won't be any more new holes just the same hole I've already made I'll just take something out of them so this isn't classed as emphysema no I don't think so you you said you didn't smoke no no you you only got emphysema yeah you're emphysema usually when you're smoking right I don't think this is emphysema certainly the blood tests that you've had haven't shown anything like that you don't have any markers of infection or anything like that going on but your tests your x-ray shows that there's a lot of fluid in your lungs fluid in the wrong place and that happens when the heart isn't able to move it very well so that could have been building over the last could have been few days even longer than that paused a cough maybe have you noticed any increased shortness of breath over the last months yeah finding it more difficult to do your normal walking on the moor and things like that unless you have to have a cough and you have a catch of breath sometimes that makes some makes more sense than it all coming on so suddenly yeah but obviously there has been some deterioration with what's going on with the arch you had a ct scan of your coronary arteries so they look lovely I doubt very much that you had a heart attack or anything like that as a cause for it but sometimes having just that bit too much fluid on board can cause your breathing to become quite difficult right so you need to get lots of wheeze to get lots of fluid out of breathing and a lot of our nurses are gonna give you all the ed and lots of wheeze so what's the saturation target for you scale 1 I think yeah so I hope that's 5% it's fine yeah it's not gonna be a retainer because it's because of copd seeing him high you don't have to have a code for these gas machines machines david don't not have have focusing on that 1 I must be in touch with you I'm looking at quick symptoms thank you okay gonna give you a minute I'm just trying to get your oxygen levels by I'm gonna give you a quick okay 0.5 exactly and then titrate and we just drop the systolic blood pressure by about 20 it's 130 at the moment so if we end up around the 100 mark 110 mark and that's lost the force and then just maintain it there just so that we can try and get as much do we need to do this post thing so yeah post force yeah we should scan her head shortly just to make sure nothing's come all there are you sure she's gonna scan her head anywhere here it's not the outside she's not all looking is you happy to just can we scan it I'm not we're better to see if I can now we might be doing just better that would be good okay no patient should come through the notes check for that just that's it your friend line is nice okay oh god good thank thank you good at that you give me minute I'm try to find the I wouldn't like it I would like to see my donor it doesn't matter yeah but I would like to a little bit of a test would look at I to take I would like take take a look at that you know you're that definitely sick to take care of any at part alright any further questions about it thank you I just prescribed 1 here spontana tiptavi has - 20 okay time me we all agree thank you and I'll set you in a sitting over as quite thank you okay what about the the vascular puncture after the toe I'm already did a doppler when there is wow so it's been a lot and who yeah did a doppler did a doppler when I sent her in the air it's still well I think the too bad a little bit yeah oh that's good too we're have look at a cold reflex okay that's good k pretty strong I always like to say twice is cold not yes no refill hi I'm rob 1 of the doctors in room your doctor's we're called pat hi pat hi I'm gonna give the bottle of a soap as well pat yes not a little bit you've got a little bit of refill there at all or can you feel them at all yeah are they painful you can feel these yeah that's a good sign I'm not I'm gonna go look ahead take at pictures okay and that's fine the box behind her yeah she's just laughing at the office are they there it's behind the so impression is acute pulmonary edema secondary to decompensated heart failure secondary to underlying cardiomyopathy off medical management following recent cardiology clinic appointment + or - and stemi and in the history of the complaint several months of worsening progressive shortness of breath on exertion last night acute shortness of breath while sat watching television denies chest pain fevers cough productive of anything but has had a dry cough over the last few months plan is diuresis intravenously nitrate infusion cpap given respiratory failure review with gases following nitrate and cpap in 1 hour if no improvement escalate again to itu and consider bipap for a brief? To stabilize things catheter eyes given will be need to be nursed in bed cce bed only discuss with cce coordinator happy to accept input output monitoring inpatient echocardiogram add troponin to bloods anti investigations bedside echocardiography grossly dilated hypokinetic globally left ventricle with very high epss no evidence of pericardial effusion or tamponade chest x-ray kerley b lines distended vasculature in the apcs bi to the mid zone hazy opacification in keeping with acute pulmonary edema add to the impression myocardial infarction felt less likely given normal recent ct coronary angiogram social history drinks alcohol 1 bottle of wine per night and has done for many years nonsmoker lives with her partner in a house on the morgue walks 5 miles up until a few months ago when sean or smith exertion limited activity