Internal Medicine Consultation Summary Letter

24/05/2024

Dr Sarah Jenkins Remuera Medical Centre, 124 Remuera Road, Auckland 1050

Dear Dr Sarah Jenkins

Re: Wiremu Patel (NHI: ZXC4829) Date of birth: 14/08/1952

Diagnosis

1. Acute decompensated heart failure (HFrEF)
2. Atrial fibrillation with rapid ventricular response
3. Type 2 diabetes mellitus

Presented with a 5-day history of progressive dyspnoea on exertion, orthopnoea (3 pillows), and bilateral lower limb oedema. Noted palpitations over the preceding 48 hours. No chest pain, syncope, fever, or productive cough.

PMH: Hypertension, T2DM, IHD (NSTEMI 2019), GORD. Regular medications prior to admission: metoprolol succinate (Betaloc CR®) 47.5 mg PO OD, cilazapril (Zapril®) 2.5 mg PO OD, metformin 1,000 mg PO BID, aspirin 100 mg PO OD.

On Examination

Mild respiratory distress at rest, speaking in full sentences. BMI 29 kg/m². BP 142/88 mmHg, HR 118 bpm (irregularly irregular), RR 22/min, SpO2 93 % on room air, Temp 36.7 °C. CVS: HS dual, no murmurs, JVP elevated at 5 cm above sternal angle, pitting oedema to mid-shins bilaterally. Resp: Bibasal inspiratory crackles to mid-zones. Abdo: Soft, non-tender, no hepatosplenomegaly.

Pathology

Hb 134 g/L, WCC 7.2 x 10^9/L, Plt 210 x 10^9/L. Na 136 mmol/L, K 4.3 mmol/L, Cr 112 µmol/L (eGFR 58 mL/min/1.73m² - baseline 65). NT-proBNP 4,250 pg/mL, Troponin T 18 ng/L (stable on repeat). HbA1c 58 mmol/mol. TSH 2.1 mIU/L.

Course And Management

Admitted to General Medicine and treated with furosemide (Lasix®) 40 mg IV BID, achieving a net negative fluid balance of 3.2 L over 48 hours with resolution of peripheral oedema and crepitations. Transitioned to furosemide 40 mg PO OD prior to discharge. Metoprolol succinate (Betaloc CR®) was uptitrated to 95 mg PO OD for rate control. Commenced on apixaban (Eliquis®) 5 mg PO BID for stroke prophylaxis (CHA2DS2-VASc 4), and aspirin was ceased. Cilazapril was switched to empagliflozin (Jardiance®) 10 mg PO OD and spironolactone 25 mg PO OD was added.

ECG: Atrial fibrillation, ventricular rate 115 bpm, no acute ischaemic changes. CXR: Cardiomegaly, upper lobe venous diversion, small bilateral pleural effusions. TTE (23/05/2024): Moderately dilated LV with global hypokinesis, LVEF 35-40 %. Mildly dilated LA. No significant valvular disease.

Discharged home stable and euvolaemic on 24/05/2024. Heart Failure Nurse Specialist follow-up arranged in 2 weeks for titration of heart failure therapy. Please check renal function and electrolytes in 7 days.

Attached: Discharge Medication List, TTE Report (23/05/2024).

With best regards, Dr David Chen, FRACP Consultant Physician, General Medicine Auckland City Hospital