Patient Case Study

1
Patient Case Study

• Julie Brown

2
P.M.H.

• Prostate Cancer (2003)
• P.T.E. (2004)
• Hypercholesterolemia
• Obesity

3
Admission May 2005.

• Decompensated C.H.F.
• ECHO severe LVSD. Mild MR.
• ECG S.R. QRS normal duration.

4
Discharge Medication

• Atorvastatin 80mg.o.d.
• Warfarin 3mg.o.d.
• Ramipril 5mg o.d.
• Frusemide 120mg b.d.

• UEs
• Na 139
• K 3.3
• Urea 6.3
• Creat 130

5
First Visit

• NYHA III
• Peripheral Oedema
• Weight 109kg
• BP 108/70 HR 94 S.R.
• K 3.4 Urea 3.8 Creat 118.

6
Intervention/Action

• Education
• Add in Spironolactone 25mg o.d.(Following D/W
  Cardiologist).

7
Subsequent Home Visit

• NYHA III(a little better)
• Peripheral Oedema
• Diarrhoea!!
• BP 112/70 H.R.92 WT 108kg
• K 3.6 Urea 5.7 Creat 121

8
Action

• Stop Spironolactone .

9
Subsequent visit.

• NYHA II
• Weight loss 2kg
• No peripheral oedema
• Dry irritating Cough persists
• K 4.0 Urea 5.3 Creat 118

10
Action

• ? ACE Cough
• Stop Ramipril
• Commence Losartan (ARB) and titrate up to 100mg
  daily.

11
Subsequent Visit

• NYHA II
• No Peripheral Oedema
• Cough settled
• BP 110/78 HR 70 Wt 107KG

12
Action

• Initiate Beta-Blocker.( Carvedilol 3.125mg b.d.)

13
Subsequent Clinic Visit

• Carvedilol 25mg b.d.
• NYHA II/III
• Peripheral Oedema to mid calf
• BP 100/66 HR 70 Wt 110kg
• K 4.0 Urea 6.3 Creat 119

14
Action

• Add in Bendroflumethiazide 2.5mg daily.

15
One Month Later

• NYHA II
• No Peripheral Oedema
• BP 106/70 HR 72 Wt 107kg
• Titrate Carvedilol up to Optimum level (50kg b.d.)

16
Subsequent Contact

• NYHA II
• C/O Light-headedness
• Feels Thirsty
• BP 90/60
• K 3.9 Urea 13.9 Creat 135

17
Action

• Reduce Bendoflumethiazide to 2.5mg on alternate
  days.

18
Current Status

• NYHA II
• Feels well
• No peripheral oedema
• On optimum anti failure medication
• Bendroflumethiazide discontinued
• On Frusemide 80 mg b.d.
• Awaiting echo to assess LV function
• Discharge to GP .