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
HOW TO WORK ON THIS ASSIGNMENT (EXAMPLE ESSAY / DRAFT)
INTRODUCTION Mr. Michael Bush, a 69-year-old man from North London, was admitted to the hospital with complaints of difficulty breathing, cough, fever, and peripheral edema. He was found to have pyrexia, tachypnea, and desaturation on room air. He had a history of severe heart failure with reduced ejection fraction, chronic kidney disease stage 3, type 2 diabetes mellitus, hypertension, and gout. He was also a current smoker and had been refusing to take his medications at home or in the emergency department due to concerns about side effects. This case study aims to discuss the management of Mr. Bush’s clinical condition and his social situation.
CLINICAL CONDITION Mr. Bush was diagnosed with decompensated heart failure due to medication noncompliance and likely community-acquired pneumonia, pulmonary edema, and desaturation. He was started on CPAP and given STAT IV furosemide to reduce pulmonary edema. He was also started on levofloxacin for community-acquired pneumonia. Additionally, he was found to have severe hypertension, for which he was put on a GTN infusion.
MEDICAL HISTORY Mr. Bush had a history of ischemic cardiomyopathy with severe heart failure with reduced ejection fraction, chronic kidney disease stage 3, type 2 diabetes mellitus, hypertension, gout, and previous long RP supraventricular tachycardia. He was a current smoker and had been intolerant of amlodipine and penicillin.
MEDICATIONS Mr. Bush was on multiple medications, including aspirin, clopidogrel, atorvastatin, gliclazide, bisoprolol, tamsulosin, and bumetanide (which he had stopped taking since December 2022). He was intolerant of amlodipine and penicillin.
SOCIAL LIFE Mr. Bush lived alone, with no formal plan of care. He was independent in activities of daily living but mobilized with a stick. He had no next of kin listed. He was a retired catering worker and had occasional alcohol consumption.
OBSERVATIONS AND MEASUREMENTS Mr. Bush’s temperature was 36.4°C, heart rate was 68 bpm, respiratory rate was 19, blood pressure was 192/95, and oxygen saturation was 99% on a 2L nasal cannula. His weight was 100 kg, and his BMI was 33.95. He had mild limb edema, and his glucose level was 14 mmol/dL.
DISCUSSION Mr. Bush’s case highlights the importance of medication compliance in patients with chronic conditions. His medication noncompliance led to decompensated heart failure and severe hypertension, which required hospitalization. Healthcare professionals need to educate patients about the importance of taking their medications and address any concerns they may have about side effects.
Furthermore, Mr. Bush’s social situation also raises concerns. He lives alone, has no formal plan of care, and has no next of kin listed. It is crucial to assess his social support and living conditions and to ensure that appropriate support is in place to prevent hospital readmissions.
CONCLUSION In conclusion, Mr. Bush’s case highlights the importance of medication compliance and social support in patients with chronic conditions. Healthcare professionals must educate patients about the importance of taking their medications and address any concerns they may have. Additionally, it is crucial to assess the patient’s social situation and provide appropriate support to prevent hospital readmissions.
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