Consultation Reflection for CPD

Date of Consultation: 14/05/2024

Patient Details

The patient is a 68-year-old male who attended the clinic with a three-week history of worsening exertional dyspnoea and bilateral ankle oedema. He has a background of hypertension and T2DM.

Key Clinical Learnings

Presenting Condition: The patient presented with progressive SOB on exertion, orthopnoea, and bilateral pitting oedema to the mid-shins. On examination, his BP was 148/88 mmHg, HR was 84 bpm regular, and bibasal crepitations were auscultated on his chest, leading the clinician to suspect a new diagnosis of heart failure.

Management Plan: The clinician discussed initiating loop diuretic therapy to manage the fluid overload and explained the importance of daily weight monitoring and fluid restriction. Safety-netting advice was provided regarding acute worsening of breathlessness or chest pain.

Investigations and Diagnostics: The clinician requested urgent blood tests including U&Es, FBC, LFTs, HbA1c, and an NT-proBNP level. A 12-lead ECG and a CXR were also arranged to evaluate for underlying cardiac ischaemia, arrhythmia, or pulmonary congestion.

Medications Prescribed: The patient was prescribed furosemide 40 mg PO OD to alleviate the peripheral and pulmonary oedema. His existing regular medications, ramipril 5 mg PO OD and metformin 500 mg PO BD, were continued unchanged pending renal function results.

Referral and Follow-Up Actions: An urgent referral was made to the Rapid Access Heart Failure Clinic for a transthoracic echocardiogram and specialist review based on the suspected diagnosis. The clinician arranged a follow-up telephone consultation in one week to review the blood results, check renal function, and assess symptom response to the diuretic.

Reflections

Learning Outcome 1: This consultation reinforced the importance of utilising NT-proBNP levels as the primary triage tool to determine the urgency of echocardiography referrals in primary care, in alignment with NICE NG106 guidelines.

Learning Outcome 2: The clinician strengthened their communication skills in explaining a potentially life-limiting diagnosis like heart failure clearly without causing undue anxiety, ensuring the patient understood the rationale for rapid investigations.

Action Plan for Future Practice

Changes to Practice: The clinician plans to incorporate a standardised heart failure template within the clinical software during consultations to ensure all baseline investigations and red-flag safety-netting points are systematically documented.

Further Learning Needs: The clinician identified a need to review the latest updates on the early initiation of SGLT2 inhibitors (such as dapagliflozin) in primary care for patients with heart failure with reduced or preserved ejection fraction.

CPD Credits: The clinician allocated 30 minutes to complete this reflection and guidelines review, which corresponds to 0.5 CPD credits.

"This reflection will be used for continuous professional development.”