A 42 year old female, presents to the Emergency Department with worsening shortness of breath. She has been unwell for a few days with increasing breathlessness and cough, which isn’t relieved with inhalers. She also reports increasing swelling of her feet and legs over the past 2 weeks.
She has a past medical history of COPD (treated with Salbutamol and Seretide inhalers), atrial fibrillation (treated with digoxin and warfarin) and had a stroke in the last year from which she has fully recovered.
On examination, she appears anxious and in distress. She is in atrial fibrillation with a ventricular rate of 140 beats per minute, blood pressure is 90/60 mmHg, JVP is raised and SpO2 are 90% on 15L/min oxygen through a non-rebreathe mask. Auscultation reveals bilateral diffuse crackles and a systolic murmur in the left lower parasternal space. Abdominal palpation demonstrates abdominal wall oedema and right upper quadrant tenderness.
An initial diagnosis of decompensated heart failure is made. Furosemide 80mg IV is administered and she is transferred to the Intensive Care Unit, where CPAP is commenced, invasive monitoring instituted and a transthoracic echo is requested.
