Case study 1 PRIMARY CARE SETTING
▪ You are a Nurse in the community and you have been asked to go and dress Mrs Smith's legs for the second time this week due to leaky legs. ▪ Mrs Smith is 83 and has carers x 4 per day; she walks with a Zimmer frame around her 1 bedroom ground floor flat. She doesn’t leave the flat ▪ When you visit Mrs Smith says she has been "out of puff" for the last week and her legs are more swollen. She says she is also finding it hard to walk to the toilet. ▪ She manages her own pills. Her medications are all over the place and Mrs Smith is a little hesitant about what she is taking. ▪ You notice incontinence pads in the corner of the room.
Past Medical History ▪ Osteoarthritis, Diabetes Mellitus (type II) ▪ COPD, Hypertension, CKD III, ▪ Ex-smoker – 40 pack years ▪ No Echo – no history of heart disease/failure/rhythm problems
Medications ▪ Adcal ▪ Alendronic Acid ▪ Amlodipine ▪ Metformin ▪ Furosemide 40 mg – has been on this for 1 year due to swollen ankles and breathlessness ▪ Co-codamol 30/500 mg QDS, PRN ▪ OTC medications – Ibuprofen 400 mg prn for her arthritis
Feedback any suggestions for action/treatment ▪ Consider: ▪ assessment, ▪ investigations and ▪ referrals
Plan ▪ Advise to take the furosemide as prescibed ▪ Educate why she needs them ▪ Refer to incontinence nurse ▪ Ask GP to review and do U&E and NT pro BNP ▪ Refer to Diagnostic HF clinic if NT pro BNP raised ▪ If she has heart failure then: ▪ Restrict fluid intake to 1.5 litres daily ▪ Daily weight recording
Scenario 2 IN-PATIENT SETTING
Mr White is 73 and was admitted 2 days ago due to increased shortness of breath over the weekend. He has a one month history of leg swelling. • He was admitted to AMU, but was transferred to a medical ward who want to discharge him. • His Bumetanide 2 mg BD was stopped on admission and he was on 80 mg IV Furosemide BD, lost 3 kg since admission. • Changing to orals as responding, weight increased by 1kg on oral furosemide 80mg BD • Mr White is not known to the heart failure service. • He is mobile and independent. Lives with wife and has 2 children visit regularly and live nearby. • Mr White would like to go home, he is worried his wife will not tend to his tomatoes in the greenhouse properly and his dog is missing him.
Past Medical History Medications ▪ Echo – Severe LVSD and ▪ Bumetanide 2 mg BD – moderate RVSD – 2012 switched to IV furosemide 80 mg BD ▪ IHD, CABG – 1998 ▪ Bisoprolol 10 mg OD ▪ Hypertension ▪ Doxazosin 8 mg OD ▪ AF ▪ Spironolactone 12.5 mg OD ▪ CKD III ▪ Warfarin as per INR and on the ▪ Ex-smoker – stopped 48 years instructions of the ago anticoagulant clinic (stable) ▪ Paracetamol PRN
Examination and findings 1 ▪ Weight 86 kg (Mr White weighs himself weekly at home and states it has increased by at least 1 and half stones (10 kg) in the last month). ▪ Blood Pressure 105/65 mmHg (sitting) 98/57 mmHg (standing) Feels dizzy on standing, but no loss of consciousness or falls ▪ Pulse 93 bpm – irregular (LBBB, QRS 166 ms) ▪ JVP Visible at jaw ▪ Oedema Moderate/severe oedema to upper thigh Sacral oedema Abdomen soft non-tender, but feels more swollen than normal ▪ Chest Quiet bases, Oxygen saturations 93% on air, apyrexial
Examination and findings 2 ▪ Sodium: 136 ▪ Normal WCC, ▪ Potassium: 4.5 ▪ CRP 12.4 (raised a bit) ▪ Urea: 10.6 (n 8.0) ▪ Normal thyroid function ▪ Cr: 130 (n 110) ▪ ECG- QRS 166ms (broad) LBBB ▪ eGFR 42 ▪ Normal LFT’s and albumin ▪ Admission chest X ray- small bilateral pleural effusions ▪ Hb 97
Feedback any suggestions for action/treatment ▪ Consider: ▪ assessment, ▪ investigations and ▪ referrals
Plan ▪ Refer to HFSN ▪ HF MDT ▪ Stop Doxazosin ▪ HFSN clinic booked ▪ Start ramipril 1.25mg on ▪ Up-titration of ACE inhibitor ▪ Daily weights ▪ Up-titrate spironolactone ▪ Restrict fluid to 1.5 litres daily ▪ DNACPR and ceiling of care ▪ Check haematinics/iron stores ▪ Consider IV Ferinject ▪ HFSN to review for Ambulatory ▪ Sacubitril/Valsartan HF unit ▪ CRT (P/D)
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