ABSTRACT
A 74-year-old man has been referred to the emergency department following an assessment by his GP, who found him to be unable to get out of his chair and with a slow heart rate of 30/min. He has had a bout of diarrhoea and vomiting over the past couple of days.
Examination On arrival an ECG is performed (Fig. 61.1). A chest X-ray shows cardiomegaly but clear lung fields. His jugular venous pulse (JVP) is visible 3 cm above the sternal angle with occasional cannon waves. He has dry mucous membranes. He has a midline sternotomy scar. The apex beat is displaced and the impulse diffuse. Heart sounds show a soft pansystolic murmur at the apex. On chest auscultation there are no crackles. Abdominal examination is normal. His ankles are not swollen. He cannot lift his legs off the bed and is generally weak. He has ischaemic heart disease, having had a coronary artery bypass graft one year ago. His other medical history is hypertension, hypercholesterolaemia, type 2 diabetes, gout, benign prostatic hyperplasia (BPH) and congestive heart failure. He has had no chest pains over the last year, although his exercise tolerance is limited to 40 metres on the flat and he has difficulty going up a flight of stairs due to breathlessness. He lives on his own in a flat, mobilizing with a frame. He is on aspirin, bisoprolol, ramipril, spironolactone, bumetanide, atorvastatin, omeprazole, metformin and allopurinol. He has no allergies. He does not smoke or drink alcohol. Observations: temperature 36.4°C, blood pressure 156/78 mmHg, respiratory rate 18/min, SaO2 94 per cent on room air.
