She is a 86 year old lady with recent admissions of recurrent pulmonary oedema.

This time again she was transferred to acute coronary unit as she needed CPAP for her type 1 respiratory failure.

When I checked her background history

• 1. Myelofibrosis under haematologist (regular transfusions)
• 2. Recent Echo: Mildly impaired LV function, not explaining her recurrent pulmonary oedema
• 3. Cardica MRI: not conclusive regarding cardiomyopathy, recommended cardiac biopsy.

She had been on CPAP, IV furosemide and daily U&E/ body weight/ fluid chart.

Her condition was improving slowly and respiratory weaned off to high flow and low flow oxygen. She was booked for cardiac biopsy. Informed consent and family meeting as usual stuffs.

In the afternoon after she came back from cardiac lab for procedure, nursing staff informed me that her blood pressure had been going down to 88/48.

I reviewed and give 250 ml of Gelofusin. Urgent echo was requested, which showed pericardial effusion.

The consultant cardiologist was informed straight way and patient was sent back to cath lab for drain. Critical out reach team involved.

Patient’s BP picked up gradually in next 12 hours. But , from next day, her renal function deteriorated. I rang renal team. They kindly came and saw patient.

After 2 weeks, her general condition improved back to her normal. Myocardial biopsy result came back as insignificant minor fibrotic changes.

We still cannot find the cause of her recurrent pulmonary oedema. It could be multifactorial.

Anyway, we will see her in clinic. Haematologist is also planning to see for her haematology problem.