Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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?