Yesterday I was called to see an 89 year old patient with a blood pressure of 60/40 (my heart rate picked up when I heard this). Details from the nurse on the phone - the rest of the obs were stable, except the sats probe wasnt picking up a reading (this worried me because it might mean the patient is so peripherally shut down that it's not picking up a reading. Patient had been admitted with sepsis (with a resultant acute kidney injury), probably due to her bilateral cellulitis, and was on the appropriate antibiotics for this. Past medical history of note included end stage congestive cardiac failure - this complicates matters when considering fluid resuscitation because if I think she's dehydrated and give her fluids too quickly I could overload her and precipitate massive pulmonary oedema which could be the end of her.
Took stairs two at a time to the ward. Patient looked unwell and SOB (short of breath), and was quite drowsy and confused (not a good sign). On examination she was very peripherally cool, with a peripheral capillary refill time of more than 6 seconds (heart sank a little at this point) central cap refill was 3-4 seconds (hmm, still longer than it should be). Heart sounds were normal, but I discovered she had bilateral crackles throughout both lungs (did she have a chest infection or was this pulmonary oedema?). As all previous chest examinations in the notes had said chest was clear I decided to repeat a chest xray (CXR). Her previous CXR from the day before showed signs of heart failure with no obvious consolidation. The rest of the examination was unremarkable. Managed to make sats probe work for a short period which showed her sats were 98% on 2L oxygen so reassured. Noted patient was already catheterised (important to allow montoring of urine output). Started 24hour bag of fluids, encouraged patient to drink (water, although we could have both probably benefitted from a brandy at this point!), with a view to having a senior review regarding IV fluids.
I decided to check her latest blood results which showed a low sodium 120 and a high potassium 5.9. Asked the nurses to do an ECG (no new changes). Checked her drug chart - she was on spironolactone which could account for the abnormal electrolytes, but with end stage heart failure there was no way I was going to stop this and would need to discuss it with a senior in any case. Also noticed she was on an ACE inhibitor so stopped this with day team to review as this may have been contributing to her renal failure.
Also on the system was a urine culture that was positive for klebsiella that she was not being treated for. Started trimethoprim (having checked the BNF regarding dosage regimen in renal failure).
Decided to repeat a full set of bloods and do an ABG (would be discussing patient with some sort of med reg who would be highly likely to want to know the results of this). Ordered CXR, instructed nurses to do hourly obs and monitor hourly input/output and ran the case past my SHO.
Went back to review the patient a couple of hours later, she hadnt deteriorated and her blood pressure was slightly better. Her CXR showed no focal consolidation (so probably not a chest infection) and worsening signs of heart failure.
Presented all of the above to the senior night team at 10pm handover (included the fact she was DNAR and her past history), and must have placated the previously disgruntled cardiology registrar who said that was a much better handover than the previous night. Gained a sense of achievement for a productive evening's work.
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