Jennifer Bell

British Heart Foundation

Heart Failure Nurse Specialist

80 year old male from Langholm

Several HF admissions to Cumberland Infirmary

Referred by GP

Frusemide increased by 40mg

History

Severe LVD

Hypertension

Allergic to ? Penicillin

Mural thrombus in LV

Bilateral subdural haematoma 2005

Parkinsons

Prostatism

Medication Zopiclone 7.5 mg prnWarfarin Sodium As per INRRamipril 10 mg odFurosemide 40 mg 2pmFurosemide 80 mg mane

Symptoms

NYHA Class IVParoxysmal Nocturnal DyspnoeaSevere Orthopnoea/Cheyne Stokes Respirations

Signs

BP (lying) 101/75BP (standing) 106/71Pulse 77 bpmRaised JVPWeight: 77.6 kg (BMI 23.2)Widespread crepsWaist oedema U & E’s, FBC satisfactory ECG – NRS freq VE’s range 53-109 min

PlanFluid restriction 1500mlsSalt reduction <5g dayIncrease frusemide by 40mgAvoid sleeping tablet and consider Oramorph? Acute hospital admission ? Palliative referralAdd SpirolactoneBeta blocker contraindicated meantimeDistrict nurses – suitable bed, pressure relieving mattress

Social work dept – benefits, carer input, OT assessment? Community hospital admissionGP visit requested and further discussion re managementConsider MetolazoneFuture D&G cardiology referral/follow-up

Actual outcome

Admitted to Community HospitalCommenced Oramorph &SpironolactoneStrict fluid restrictionDischarged home 12 days later

with community support

3 months later:

NYHA Class III Progress stableBP (lying) 123/79BP (standing) 117/78Pulse 58 bpm Weight: 68 kg (BMI 20.3)Few crepsNo oedema

Warfarin Sodium Ramipril 10mgSpironolactone 25mgBisoprolol Fumarate1.25mgFurosemide 40mg 2pmFurosemide 80mg mane

Oramorph 2.5mg prnPicolaxMacrogolsLactuloseSenna

COMMENTS / QUESTIONS / SUGGESTIONS FOR FUTURE

? Palliative care referral/joint management

? Dietetic referral

? Cardiology follow up

? Candesartan

? Resynchronisation therapy if criteria met

? Up titrate beta-blocker ? try Nebivolol

? Change nothing meantime