PRESENTING COMPLAINTS- Difficulty breathing

Posted: May 5th, 2020

ASSIGNMENT INSTRUCTIONS:
CASE STUDY
PRESENTING COMPLAINTS- Difficulty breathing
ICU clinical summary-
1) Decompensated heart failure due to medication noncompliance and likely community-acquired pneumonia pulmonary edema and desaturation.
– Started on CPAP
– STAT IV furosemide given.
– Started on levofloxacin for CAP.
2) Severe hypertension – On GTN infusion
Mr. Michael Bush a 69-year-old man from north London had been admitted to the hospital due to shortness of breath, paroxysmal nocturnal and peripheral edema with cough and fever, found by the ambulance crew to be pyrexial, tachypnoea (RR28/min) and desaturated to 80%on room air. Known severe heart failure with reduced ejection fraction who had been refusing to take his medication at home or in A&E due to concerns around side effects and was lost to cardiology follow up
PAST MEDICAL HISTORY
1) Ischemic cardiomyopathy with severe heart failure with a reduced ejection fraction
– Coronary angiogram- May 2022: severe LCX and RCA stenosis.
– CTA February 2023: LV ejection fraction 33%. Moderately severe functional mitral
regurgitation. All myocardium viable
2) Chronic kidney disease stage 3
3) Type 2 diabetes mellitus
4) Hypertension
5) Gout
6) Previous long RP supraventricular tachycardia
7) Current smoker
This visit
At the risk of venous thromboembolism
ongoing
Acute heart failure
Acute pulmonary edema Diabetes mellitus
HTN- hypertension sciatica
Drug History
– Aspirin 75mg OD
– Clopidogrel 75 mg OD
– Atorvastatin 40 mg OD
– Gliclazide 80mg BD
– Bisoprolol 5mg OD
– Tamsulosin 400mg mcq OD
– Bumetanide 1 mg OD – stop taking since December 2022
Intolerant of amlodipine and penicillin
SOCIAL LIFE
– Smoking status: Current smoker- 4-5 cigarettes a day and previously a heavy smoker (40-50)
– Alcohol consumption: occasional alcohol consumption
– Occupation: Retired – previously worked in catering
– Lives alone. No formal POC- Independent ADLS. Mobilise with a stick. No next of kin is listed.
Under cardiology team
REVIEW OF SYSTEM
A) Self-ventilating
B) Nasal cannula RR 15-28bpm FI02 2L sats 94% reasonable arterial gas exchange, slightly
reduced air in both lungs bases
C) On GTN intermittently B/P 145/65mmhg, HR 62 bpm, sinus lactate 1.6
D) GCS 15/15 no sedation
E) Mld limb edema, calves SNT
F) Currently FB-VE 450mls
G) Glucose 14mmols/dl
H) Prophylactic Tinz, INR 1.0, HB 105, no bleeding
I) Apyrexial Levo D4, vacate and CVC D2, WBC 6.7(6.5) crp 59(119)
OBSERVATIONS AND MEASUREMENT
Temp 36.4 oC HR:68( monitored) RR: 19 BP: 192/95, BP: 135/64 (line) SPO2: 99% WT:100kg BMI: 33.95

Based on the information provided, Mr. Michael Bush is a 69-year-old man with a history of ischemic cardiomyopathy with severe heart failure with a reduced ejection fraction, chronic kidney disease stage 3, type 2 diabetes mellitus, hypertension, gout, and previous long RP supraventricular tachycardia. He was admitted to the hospital due to shortness of breath, paroxysmal nocturnal and peripheral edema with cough and fever, found by the ambulance crew to be pyrexial, tachypnoea (RR28/min), and desaturated to 80% on room air. He has been diagnosed with decompensated heart failure due to medication noncompliance and likely community-acquired pneumonia pulmonary edema and desaturation, for which he has been started on CPAP and given STAT IV furosemide. He has also been started on levofloxacin for CAP and is on a GTN infusion for severe hypertension. His drug history includes Aspirin 75mg OD, Clopidogrel 75 mg OD, Atorvastatin 40 mg OD, Gliclazide 80mg BD, Bisoprolol 5mg OD, Tamsulosin 400mg mcq OD, and Bumetanide 1 mg OD, which he stopped taking since December 2022. He is intolerant of amlodipine and penicillin. He is a current smoker, previously a heavy smoker, and occasionally consumes alcohol. He is retired, previously worked in catering, lives alone, and has no formal POC. He is independent in ADLs, mobilizes with a stick, and has no listed next of kin.