The rest of yesterday's on call shift went rather well. I was called to see a patient I had treated for pulmonary oedema on Friday when he was admitted. He had had a stroke and a proper swallow assessment hadnt been done so he had been made nil by mouth and not received any of his oral medication to stop him going into heart failure again over the weekend, so he promptly went back into heart failure and was feeling awful. It would have been helpful if one of the nurses doing the drugs round had alerted a doctor that he couldnt take his meds.
I examined him and wrote up the same treatment he had had on Friday - 40mg IV Furosemide and 2.5mg IV diamorphine. I repeated the CXR and did an ABG. He was quite tachycardic and said he had chest pain so did an ECG. Asked nurses to do hourly obs and monitor fluid input/output.
I was slightly concerned this chap might also have a pulmonary embolism as the ECG showed sinus tachycardia, the chest pain sounded pleuritic (worse on taking a deep breath), his ABG had a very low PaO2 [7.6 EEK increase the oxygen!] and I found a tender right calf on examination. Quite difficult to know what to do about this as therapeutic dose clexane is contraindicated with a large ischaemic stroke as it carries a high risk of bleeding. He probably wasnt a candidate for inferior vena caval filters (to prevent a thrombus travelling from a DVT in the leg to the lungs).
Decided to discuss with the med reg, who came to see the patient. She suggested starting a GTN infusion because the patient's blood pressure was stable at 150 systolic (GTN is likely to drop the BP considerably so should be started with caution.) She also said well done, which gave me some reassurance that I do have a vague idea about what I'm supposed to be doing!
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