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Tip: Focus on heart failure management and admission decisions.
Inspector
Doctor Notes
Patient Information
Name: Margaret Davies
Age: 78 years
Gender: Female
Current Appointment
Telephone consultation - arranged by sheltered housing staff due to increased breathlessness and ankle swelling
Past Medical History
- Myocardial infarction & two-vessel PCI in 2000
- Chronic heart failure (LVEF 35%)
- Hypertension
- Type 2 diabetes (diet-controlled)
- Osteoarthritis knees
- Chronic kidney disease stage 3b
Current Medications
- Atorvastatin 40mg ON
- Clopidogrel 75mg OD
- Bisoprolol 5mg OD
- Ramipril 5mg OD
- Bumetanide 1mg OM
- Metformin 500mg BD
- Paracetamol 1g PRN
- Timolol eye-drops BD
Recent History
Last consultation: 1 month ago - cough with yellow phlegm and fevers. Treated with Amoxicillin for presumed chest infection. Not seen since then.