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An 85 years old housebound lady, Mrs Pace, requests a home visit due to dizziness and palpitations which started a week ago.

 

She reports feeling light-headed at times when her heart can race. She denies any vertigo, syncope or chest pains. She has COPD, with breathlessness limiting her mobility. She also has a background of angina and hypertension. The team decide to visit her at home to gather some more information…

Dizziness
Blood pressure

The visiting Nurse Practitioner, David, checks her observations.

 

  • David has difficulty auscultating Mrs Pace’s heart sounds because of her hyperinflated chest.

  • It’s difficult feeling a radial pulse - perhaps hardened arteries?

  • The pulse oximeter isn’t giving David an accurate reading- Mrs Pace’s hands feel cold (she admits leaving the heating off due to concerns about the cost).

  • The automatic blood pressure machine keeps saying “error”, so David takes a manual reading - 110/68mmhg with no postural drop. Her resting heart rate is around 100-110 bpm.

  • A tympanic thermometer shows her temperature is 36.6.

  • Examination is otherwise normal (eg. no cerebellar signs).

David suspects Mrs Pace has an arrhythmia, but has difficulty confiming this by examination alone, even with all the tech... 

David feels an ECG and blood tests are needed.

He speaks with Magdalena, the practice healthcare assistant, who is happy in theory to visit Mrs Pace to take bloods and an ECG recording. However, she’s concerned about the practicalities of getting the machine into Mrs Pace’s house and getting an accurate trace.

ECG result
Old lady

Magdalena has heard about a new KardiaMobile device, which she thinks would be much easier to use…

So she approaches the GP partners to suggest the practice buys one to help with patients like Mrs Pace. The partners agree, reflecting it could be used opportunistically in practice if someone’s pulse feels irregular, whilst it could also be taken on home visits if clinicians suspect a patients’ symptoms may be related to a heart problem.

Magdalena gives a presentation at the next practice meeting on how to use the device and writes a short instruction sheet which she shares with the team.

Magdalena also works with David to develop an audit sheet which is kept with the device to see how often it is used by whom and for what. She plans to review this data and feedback the findings to the practice team in 3 months.

Mrs Pace is diagnosed with atrial fibrillation, with a rate of 115 bpm. Her blood tests reveal no electrolyte abnormalities, anaemia or thyroid problems.

David explains to Mrs Pace how her fast heart rate means that her heart isn’t having time to fill up, so it isn’t pumping as much blood to her brain. He explains this is what is making her feel dizzy.

 

He describes how a medication to slow her heart rate down could allow the heart more time to fill and reduce the dizziness. She is eager to try the medication as she is worried about falling whenever she tries to walk between rooms.

Tablets
Anticoagulant

Mrs Pace declines any referral for an echocardiogram to rule out any heart valve problem as she doesn’t want to go to the hospital. She also says she doesn’t want any ‘blood thinners’, despite David talking with her to explain about the risk of stroke.

David is concerned about Mrs Pace decision about having an anticoagulant, so he approaches a WiseGP at his practice for advice.

Together they see and talk with Mrs Pace, confirming her capacity. They explore her understanding of how anticoagulants could help and harm her. They find that she is too worried to take them as her husband died of a brain haemorrhage following a fall whilst on warfarin. Using all this information, the WiseGP negotiates a tailored plan with Mrs Pace. They agree to revisit her decision about anticoagulation after she has been on bisoprolol, when she can see if her dizziness, hence her falls risk, has reduced.

After discussion, Mrs Pace is also happy for David to ask the social prescriber to contact her about financial support for her heating.

David visits Mrs Pace in a month. Her dizziness has resolved, her heart rate is stable at 68 bpm. She says she will try the ‘blood thinners’ as her cousin recently had a stroke which led them to require nursing care and she is eager to maintain her independence.

Mrs Pace is extremely grateful that David arranged for the social prescriber to contact her as she’s got the extra fuel allowance she needed to keep her heating on and says it’s transformed how well she feels.

David reflects how rewarding it was to follow-up the case of Mrs Pace and that by exploring her ideas about anticoagulation they were able to negotiate a plan which ultimately led to her being on the best treatment for her.

The WiseGP reflects on the importance of team management and arranges case review sessions, when all the team can  look at and learn from similar cases.

Fire
Happy Woman

Magdalena has suggested use of new technology to improve patient care and save time and been supported to work on an audit, whilst David has developed his shared-decision making skills with the support of a WiseGP at his practice.

Read more about wearable health technology in our WiseGP newsletter titled “My Smartwatch Says…”.

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