HHD 9 Accident and Emergency Report

Patient information
71 year old Mr. P. K. was clerked at the Newham Accident and Emergency
Department
Currently resides in a residential care home. Moved to London from Uganda in
1992. Served as a pilot in the military forces.
Main complaint / History of presenting complaint
3 day ago Atypical chest pain likely Gastritis / GORD
Chest pain has developed with worsening symptoms:
Site: Left side of chest and epigastric area
Onset: Spontaneous at rest, lasts for 3 hours
Character: Burning and crushing pain
Radiation: radiates down to epigastric area
Associated symptoms: Swollen ankles
Time lasted 3 days
Exacerbating factors: Difficulty walking due to breathlessness on exertion
Alleviating factors: Eating
Severity: 7/10
Relevant background information
He has had significant cardiac and renal problems which have required close
monitoring.
Hypertension and raised cholesterol
HIV & Hep C
Severe pneumococcal pneumonia and septicaemia
Oral Candidiasis and Pancytopenia
Chronic Varicose veins / Eczema
Weight Loss and Anaemia
Previous persistent microscopic haematuria and renal impairment
A cystoscopy procedure in July 2001 required hospital admission a few weeks
later due to severe e-coli septicaemia secondary to urinary tract infection

Drug History
Nevirapine 200mgs bd
400mgs bd

Stavudine 40mgs bd

Aciclovir

Dapsone 100mgs od
od

Lamivudine 150mgs bd

Ramipril 5mgs

Folinic acid 15mgs od

Social History
Lives in care home with others
Toilet, bathroom, and Bed downstairs
Review of the Systems
Gastrointestinal: Appetite is normal, eating relieves chest pain
Genitourinary: Urination and opening bowels normal
Musculoskeletal: fatigue in muscles of inspiration
Neurology: Bout of dizziness in the morning when showering
Respiratory: Breathlessness at night Nocturnal dyspnoea. Sleeps on 1 pillow

Patient examination findings

Assessed chest expansion: Percussion on both sides, no asymmetry. Noted chest

expansion laboured.
Inspected patients hands: Warm to touch. No signs of nail clubbing, splinter

haemorrhages, palmar erythema, janeway lesions, oslers nodes, and nicotine staining
Recent heart murmurs: Auscultation performed for all four valves of the heart in the

following areas:

Mitral valve where the apex beat was felt.

Tricuspid valve on the left edge of the sternum in the 4th intercostal space.

Pulmonary valve on the left edge of the sternum in the 2nd intercostal space.

Aortic valve on the right edge of the sternum in the 2nd intercostal space.

= Pan-systolic murmur detected indicating mitral regurgitation / tricuspid

regurgitation

 Check for mitral stenosis: over the apex and axilla with patient laying on their left side,

asked to breathe in, then out and hold it out.

Aortic incompetence confirmed over the aortic area with patient asked to sit forward,

repeat the breath in, out and hold.

Percussion to estimate margins of the liver:
Light percussion, with the doctor's ear close to the abdomen, helped determine the lower border of
the liver. Mr P.Ks lower margin extended lower than the normal boundary of right costal margin. This
was confirmed with Single-handed palpation with exquisite tenderness felt by the patient, and liver
firmness noted

Abdomen examination: Bowel sound present with stethoscope. Tenderness in

epigastric area
ECG:

ST elevation and T wave inversion indicate Left Ventricular hypertrophy strain

patterns.
Pulse

84 AF

Jugular venous pressure visible 3cm above clavicle

Pitting oedema to the knees with a raised JVP

Premorbid functional status

Can Wash independently Can dress independently
Can feed
independently
Can transfer independently Can walk
independently
Can climb stairs independently
Can prepare
meals independently Can do shopping independently Can do domestic tasks
Patient Management
Problem list
Chest pain, fatigue, breathlessness, nocturnal dyspnoea
Emergency investigations
Blood pressure/Pulse

ECG

Blood Collection tubes:

purple top tube for complete blood counts (CBC) ; Light blue top tube for
coagulation assays (prothrombin time (PT), partial thromboplastin time (PTT), and
thrombin time (TT)) ; Pink top tubes used for routine immunohematology.

Urinary analysis
Temperature
Swab test
BMI

Definitive diagnosis
Severe aortic regurgitation with heart failure, mitral and tricuspid regurgitation
leading to
UNCOMPENSATED RIGHT HEART FAILURE with associated congestive
hepatomegaly and pitting peripheral oedema
Management plan
Consultant noted that Atypical chest pain may likely be gastritis / GORD. Not
commenced on aspirin because of GORD symptoms.
Referral to anticoagulation clinic follow up for initiation of warfarin.

Blood tubes sent for investigation.

Self-reflections
Summary of challenges encountered during patient management and how they
were overcome
Mr P.K communicated that while he was lying supine and in between seeing the
nurse and having to wait for the consultant, he felt an episode of breathlessness
coming on. The arrival of the consultant put him at ease. But this could have
been a potentially urgent situation which shows how the patients condition can
change from non-urgent to critical in an instant and so it is important that
practitioner is alert at all times.
It was difficult to get an accurate description of symptoms from Mr P.K. He first
described a burning chest pain but when asked if his chest felt heavy, he
affirmed the feeling of a crushing chest pain. Also, on review of systems, Mr.PK
claimed to not be getting headaches or light-headedness but his story about
bending down in the shower making him feel bad indicated to the consultant
the experience of dizziness. Ambiguity in the exact nature of his symptoms
posed a challenge when coming to decide on the exact definitive diagnosis that
matched his symptoms, and it left open question marks as to whether there was
more than one condition implicated in his chest pain.
Likely challenges that would be encountered when managing the patients oral /
dental health
This is a resident of a care home. His current condition means that he is
practically chair-bound. Which makes accessing a dental chair at a clinic difficult.
His current state means that he is fatigued and must stop after walking only 10m
due to shortness of breath. Where possible, visits could be made to his care
home to carry out simple treatment. (eg. Patching up fractured teeth, Use of GIC
on posterior teeth, Carisolv caries removal, Copy dentures).
Depression and dementia are widespread amongst care home residents. Mr P.K is
in his 70s and early onset dementia can begin to to set in before the age of 65,
which could affect communication with him and his ability to understand. impair
his ability to comply with oral care procedures and adapt to new techniques. With
Mr P.K mentioning that he expects to be on his death bed soon, it is likely that he
may be neglectful of his oral hygiene.
Chronic health problems can interfere with his treatment plan. Medications for
these conditions may have side-effects that make periodontal stabilization
difficult. Anti-hypertensives he is on are likely to induce xerostomia. Also, his
cardiovascular conditions and breathlessness would affect tolerance to dental
care and makes treating in a supine position difficult. There would be obstacles in
terms of the positioning of the dentist and patient. Appointments would have to
be kept short and Atraumatic restorative treatment would have to be used where
possible.