Case 79: Betty Ward

INSTRUCTIONS FOR THE DOCTOR

This is a short case.

Please take a focused history from Betty and manage the issues that arise.

Last week you noted:

• Feeling well, no new issues

• BP 110/70

• Pulse 95 bpm irregularly irregular

• CVS—heart sounds dual, nil added, JVP three cm above sternum, no swelling of ankles

• Respiratory—respiratory rate: 26 breaths/min, sats 94% on room air, no dyspnoea at rest, decreased breath sounds globally on auscultation (long-standing)

• Spirometry—FEV1 54% predicted, no significant reversibility (FEV1 58% six months earlier)¹

• FBE, LFTs and electrolytes all in normal range

• INR 2.7.

The following information is on her summary sheet:

• Past medical history

• Atrial fibrillation (non-valvular)

• COPD

• Hypertension

• Medication

• Warfarin (dose variable, currently 3 mg OD)

• Perindopril 4 mg

• Salbutamol 100 mcg 2 puffs prn

• Fluticasone propionate/salmeterol xinafoate 250/50 mcg 1 puff bd

• Tiotropium bromide 18 mcg one daily

• Allergies

• Nil

• Immunisations

• ADT, influenza and pneumococcal immunisations up-to-date

• Social history

• Retired school teacher, lives alone

• Widowed 18 months ago, no children

• Ex-smoker (40 pack/year history; quit three years ago)

• No alcohol.

INSTRUCTIONS FOR THE PATIENT, BETTY WARD

Last week you booked a last-minute non-refundable special deal to go on a three-week trip to Europe (Germany, France, Switzerland, Italy), leaving in four weeks’ time. You don’t have a travel companion but will be joining a tour group of older travellers the day after you land in Europe. It has been a lifetime dream to ‘see Europe’ but your husband didn’t like to travel, and you’ve never been overseas before.

On specific questioning:

Your travel agent reassured you that the pace of the tour will be ‘sedate’ and that they ‘will take good care of you’. You have not yet investigated travel insurance options. You live independently but can walk only 30 to 40 metres without ‘stopping to catch a breath’. You have been on warfarin for four years and have monthly INR tests. Your INR results have been stable and you have not required any dose adjustment for more than six months.

You are happy to see a respiratory physician if this is recommended, as long as it can be done before your trip.

The following information is on your summary sheet:

• Past medical history

• Atrial fibrillation (non-valvular)

• COPD

• Hypertension

• Medication

• Warfarin (dose variable, currently 3 mg OD)

• Perindopril 4 mg

• Salbutamol 100 mcg 2 puffs prn

• Fluticasone propionate/salmeterol xinafoate 250/50 mcg 1 puff bd

• Tiotropium bromide 18 mcg one daily

• Allergies

• Nil

• Immunisations

• ADT, influenza and pneumococcal immunisations up-to-date

• Social history

• Retired school teacher, lives alone

• Widowed ...