Download Case scenario HF2

CLG Term 2, Meeting 2 Heart failure: Management of Heart Failure
Learning Outcomes for this session:
1. Provide personalised care and weigh up and pros and cons of treatment.
2. To consider the various issues/challenges of treatment from :
healthcare professionals’ perspectives
patients’ perspectives
relatives’ perspectives.
3. Understand the impact of the diagnosis of Cardiac problems and Heart Failure on the
patient and their family
4. To improve communication of results of investigations with patients.To have strategies
to help patients who are medically complex and have problems with engaging with
services by increasing one’s awareness of community and secondary care resources.
5. Increase confidence in interpreting results of tests for breathlessness such as
Echocardiogram, or having access to someone who can interpret the results if these are
uncertain.
_________________________________________________________________________
Mr Sanjay Shah, Aged 75
Mr Shah had presented 4 weeks ago with breathlessness on exertion. He is the main carer for his
wife with long term schizophrenia and has no care package. He has a son at University, who helps
him in the holidays, and one son who has left home. Initial investigations suggested that he had
Heart Failure ( raised BNP , stable spirometry suggestive of moderate COPD) He had declined a
hospital referral but agreed to have some medication to help his breathing.
Following on from the investigations and history previously, Mr Shah was commenced on the
following by his usual GP, Dr. Roberts:

Bisoprolol 2.5mg, daily

Ramipril 2.5mg, daily

Frusemide 40mg, daily
Mr Shah reported feeling less breathless on the above medications and was subsequently followed
up by the practice’s GP Registrar, Dr. Keen who has increased Mr Shah’s Ramipril to 5mg daily and
Bisoprolol to 5mg daily. A 24h ECG report shows Paroxysmal Atrial Fibrillation and despite several
discussions with Dr Keen, Mr Shah declines anticoagulation citing reasons of not wanting to go to
appointments for warfarin monitoring. One month later, Mr Shah attends the surgery to see Dr Keen
for a review. He is accompanied by his youngest son, Dilpreet who has just arrived back from
university for the summer holidays. Dilpreet reports that his father recently had a fall after getting
up too quickly to answer the front door. In a panic Dilpreet called 999 and the paramedics had come
to assess Mr Shah. Whilst the LAS report stated that Mr Shah had not sustained any major injuries
he was very shaken up and had reported feeling very dizzy before falling. His BP had been 106/64
pulse 58 when he had been assessed by LAS.
Dilpreet raises concerns that his parents are not coping at home. He reports that the house smells of
urine as his father cannot get to the toilet upstairs in time since starting the diuretics and is
frequently wetting himself. He is suspicious that his father might have stopped the frusemide due to
this. Dilpreet is also concerned that both his parents are only eating ready-meals and sandwiches
when he is away and that their personal hygiene has deteriorated. His mother is spending most of
her time in bed and neglecting her self-care. He also reports that his dad is now avoiding going out
altogether and seems to be drinking a lot more sugary tea which helps him when he feels a bit
shaky.
His most recent kidney function tests are as follows:
June 2015
eGFR
U&E
April 2015
51
70
Serum sodium
133
141
136.00 - 145.00mmol/L
Serum potassium
5.6
4.5
3.50 - 5.10mmol/L
Serum creatinine
121
87
64.00 - 111.00umol/L
Thyroid function test
Serum free T4 level
Serum TSH level
Full blood count ! Haemoglobin estimation
Total white cell count
Platelet count
! Mean corpuscular volume (MCV)
Red blood cell (RBC) count
! Haematocrit
! Mean corpusc. haemoglobin(MCH)
! Mean corpusc. Hb. conc. (MCHC)
Red blood cell distribut width
Neutrophil count
Lymphocyte count
Monocyte count
Eosinophil count
Basophil count
Nucleated red blood cell count
16.7 pmol/L
2.05 mu/L
128
8.5
219
77.7
5.20
0.404
24.6
317
14.7
5.7
1.7
0.9
0.2
0.1
<0.2
g/L
x 10*9/L
x 10*9/L
fL
x 10*12/L
l/l
pg
g/L
%
x 10*9/L
x 10*9/L
x 10*9/L
x 10*9/L
x 10*9/L
x 10*9/L
Examination Findings
Mr Shah appears dishevelled and slightly breathless on walking into the room.
9.00 - 19.00pmol/L
0.35 - 4.94mu/L
130.00 - 180.00g/L
3.50 - 11.00x 10*9/L
130.00 - 450.00x 10*9/L
78.00 - 100.00fL
4.50 - 5.50x 10*12/L
0.45 - 0.50l/l
27.00 - 32.00pg
320.00 - 360.00g/L
10.00 - 15.00%
2.00 - 8.00x 10*9/L
1.00 - 4.00x 10*9/L
0.20 - 1.00x 10*9/L
0.00 - 0.40x 10*9/L
0.00 - 0.10x 10*9/L
<0.20x 10*9/L
BP Sitting 140/82
BP Standing 122/70
HR 55 bpm, reg
Past Medical History
Type 2 diabetes
2013
COPD
2010
Hypercholesterolaemia
2007
Hypertension
2005
BMI 31
1998
Ex-smoker: gave up 3 years ago. 25 pack years
Medication
Metformin 1gm twice daily
Gliclazide 80 mg bd
Atorvastatin 20mg at night
Amlodipine 10mg once daily
Seretide 125 2puffs twice daily
Tiotropium Inhale 1 capsule through device once daily
Frusemide 40mg once daily
Bisoprolol 5mg once daily
Ramipril 5mg once daily
Small Group Work
Questions to consider:
1. What issues does this scenario raise?
2. What would be your next steps and what resources are available to help you with
this?
3. What would you say to Mr Shah about his condition?
4. What would you say to Mr Shah and his son about what might/needs to happen
next?