Assignment Scenario: The focus of the scenario will be a patient with Coronary Heart Disease as a long term condition

Assignment scenario management of heart failure

Denise Wilmington is a 70 year old lady who has sustained both inferior and anterior myocardial infarctions five and three years ago respectively. Over the last year she has complained of gradually increasing fatigue and oedema despite increasing diuretic therapy. She is currently being treated with frusemide 80mg three times daily, captopril 50mg three times daily, asprin 150 mg once daily, isosorbide mononitrate SR 60mg once daily and amlodipine 10mg once daily. Over the last 6 weeks her fatigue has been getting increasingly worse and she has been unable to work more than a few hours a day. Denise is a solicitor and spends much of her working day seeing clients in her office in Central London. She drives to the office, leaving her home at 6.30 in the morning. Her only hobby is golf, but she has played very little recently. Denise is the main carer for her husband who has COPD and is virtually housebound, although fiercely independent. They have one daughter who lives in Australia. When Denise is at work, her live in housekeeper helps her husband. This week Denise has been reviewed by her cardiologist. On examination she had some pitting oedema to both ankles and basal fine crepitations. She had a resting tachycardia of 105 beats per minute in sinus rhythm. The chest x ray showed minimal interstitial oedema, a small right sided pleural effusion and marked cardiomegaly. Abdominal examination revealed a small degree of hepatomegaly and Denise has lost 5 kgs since her last appointment. The cardiologist noted that Denise appeared quiet and somewhat withdrawn and was reluctant to enter into a dialogue about current and future treatment options. The cardiologist suspected that Denise is not taking all her medicines as prescribed as she has reported some side effects from them, but again Denise just shrugged and appeared not to want to discuss her medication further. Consequently the cardiologist decided not to alter Denises medication at present, but has asked the GP and Community Matron to follow up her care; the Cardiologist has also suggested to the GP that he asks for a psychiatric referral as he suspects Denise may have some depression.