ABSTRACT
A 78-year-old woman has presented to the emergency department with acute severe shortness of breath and wheeze. Over the past 2 hours this has been increasingly severe. She has no chest pain, cough or fever. Her medical history includes hypertension, peripheral vascular disease and chronic kidney disease stage 4. Over the past year her estimated glomerular filtration rate has deteriorated by two-thirds and her hypertension has become more treatment-resistant, accompanied by reduced exercise tolerance, orthopnoea and bilateral lower limb oedema. Of note, this is her third similar presentation to the hospital in the past year. She is taking several drugs: hydralazine, 50 mg thrice daily; isosorbide mononitrate, 60 mg once daily; nebivolol, 5 mg once daily; spironolactone, 25 mg once daily; furosemide, 80 mg twice daily; amlodipine, 10 mg once daily; aspirin, 75 mg once daily; atorvastatin, 10 mg once daily. She has no known drug allergies.
