Case-based
discussion
Aarthi Sakthivel
Height= 147.3cm
Introduction to patient-
Weight= 71.2kg ->BMI was
calculated to be 32.8 so
the patient was
Reason for admission
therefore obese.
Mrs H.R, an 83 year old patient was admitted to Culpepper
ward due to the presence of chest tightness and shortness of
breath.
Intolerances
Allergies/Sensitivities -Atorvastatin
Doxazosin=Adverse -Perindopril
-Rosuvastatin
reaction
-Bisoprolol->Unknown but since then
Phenoxymethylpenicillin=
has been taking the medicine->Why is
rash still noted as an intolerance in the
record?
Past medical history
About Mrs H.R.
-Severe aortic stenosis
-Atrial fibrillation
-Renital vein thrombosis
-Trans ischaemic attack twice
-Percutaneous coronary intervention+stent
-Ischaemic heart disease
-Hypertension
-Osteoarthritis
-Insomnia
-Heart failure with preserved ejection fraction
Past Medication
history
Medication Indication
Rivaroxaban 20mg OD Atrial fibrillation
Bisoprolol 2.5mg OD Heart failure
Codeine 15-30mg OD PRN Pain relief
Furosemide 40mg BD Oedema+Heart failure
Paracetamol 1g QDS PRN Pain relief
Senna 7.5mg OD PRN Constipation
Valsartan 160mg OD Heart failure
Results Monitoring
Creatinine has a steady decrease from 108micromol For this patient we would have to monitor the cardiac function
per litre to 104 micro moles per litre with one through measuring the blood pressure andheart rate,stool chart as
fluctuation.The serum urea decreased within a the patient is currently taking opioids,creatinine should also be
period of five days.The blood pressure is slightly low monitored so that dose adjustments can be made if required.Once
for Mrs H.R for her age and this makes her at an creatinine is calculated creatinine clearance can be calculated using
increased risk of falls.There is also average blood Cockcroft-Gault equation.
pressure was calculated to be 128 systolic and 76
diastolic. The patient’s heart rate remains within the
normal range for heart rate but is on the higher side
of the range.This is expected for her as she does
have decompensated heart failure with reduced
ejection fraction so the heart is having to work
harder to perfuse the blood to
circulation.Respiratory rate remains within range
averaging at an average of 17-18 breaths per minute.
Possible diagnosis
Differentials and possible diagnoses What changes were recommended in relation to
the diagnosis?
Symptoms can possibly suggest symptomatic
For the aortic stenosis, Transcatheter aortic
aortic stenosis, fluid overload due to
valve implantation(TAVI) was recommended to
decompensated heart failure with preserved
improve blood flow in the heart by replacing.
ejection fraction. There could possibly be a
This is good as this can improve chest pain and
lower respiratory tract infection.
breathlessness.
Some other conditions might be present with For the fluid overload, Furosemide was
shortness of breath.These can include prescribed and given IV.
Asthma,COPD,Angina,Heart attacks
Pneumonia and sometimes lung cancer, Lower respiratory infection was ruled out, due
to no abnormalities in the WBC count.
Intervention 1-Home medication was not
initiated in hospital
Patient was taking Codeine for pain relief and was experiencing opioid induced-
constipation and was not prescribed any medicines for constipation. An intervention
was made where the Senna was initiated.It is currently on the drug chart. Another issue
was noticed, based on the patient medical history, in patients with opioid-induced
constipation, an osmotic laxative and a stimulant laxative is recommended but as per
the GP’s summary care record only Senna was prescribed. Macrogol was initiated
alongside Senna in hospital once the intervention was made.
Intervention 2-
Rivaroxaban dose
change
Rivaroxaban dose was changed from 20mg once daily to 15mg
once daily. This was because NICE Guidelines recommend a dose
reduction to 15 mg once daily if creatinine clearance 15–49
mL/minute. Given that the creatinine clearance was calculated
to be 39ml/min on 28/01/25. The creatinine clearance on
02/02/25 was calculated to be 41ml/min which was an
improvement in creatinine clearance.
28/01/ 29/01/ 30/01/ 31/01/ 02/02/
25 25 25 25 25
Creatinine(micromole/litre 108 105 N/A 100 104
)
Intervention 3- Quinine prescribed in
patients with cardiovascular problems
Quinine has been associated with dose-dependent QT-interval-
prolonging effects and should be used with caution in patients
with risk factors for QT prolongation or in those with
atrioventricular block.Mrs H.R has a past medical history of
AF,HF and Aortic stenosis along with TIA twice so she is already
at an increased risk of cardiovascular complications compared
to normal individuals.There is also a poor risk to benefit ratio.
Non-pharmacological treatment can include active
stretching,massaging the affected muscle can reduce the
frequency of cramps.Vitamin B Complex,Magnesium,Vitamin E
and Diltiazem have been recommended as a possible alternative
to quinine.
Intervention 4: Prescribing pattern does not follow Heart failure
guidelines
No Perindopril
Not adding Perindopril does not follow the NICE Guidelines for Heart failure.Whsn
Bisoprolol is prescribed alongside Ramipril can decrease the risk of morbidities and risk
but patient is intolerant.Patient is also currently taking Valsartan so it would not be
appropriate if Valsartan was prescribed alongside an ACE Inhibitor.As per NICE
Guideline,Beta blockers should be prescribed alongside ACE and diuretics such as
Furosemide and Spironolactone can be recommended for symptomatic management of
heart failure and Ivabradine and or Sacubitril and valsartan in combination and SGLT2
inhibitors can be recommended.
Patient is also not prescribed Statins due to there being an intolerance but patient is at
increased risk of cardiovascular complication.The benefits do not outweigh the risk as a
reduction of 40% LDL is required and the patient may not get the full benefit of statin.
Thank
You
FOR LISTENING
