Mrs. Agu , a 68-year-old female presents to ED at 0400hrs with worsening shortness of breath over last 2 days and sudden onset chest pain this morning. Ongoing  productive cough and nocturnal shortness of breath last 2 weeks

• Mrs. Agu , a 68-year-old female presents to ED at 0400hrs with worsening shortness of breath over last 2 days and sudden onset chest pain this morning. Ongoing  productive cough and nocturnal shortness of breath last 2 weeks.
• Chest pain 2/10 right sided, non-radiating, non-pleuritic. Denies palpitations.
• Complains of nausea, lightheadedness
• Sitting up, appears unwell, is diaphoretic
• Past Medical History: DM Type 2, Complete heart block  Cardiomyopathy, LVEF 29% in October 2021,  Permanent Pace-Maker Insertion 2020, Lower limb ulcers, Left Bundle Branch Block, Chronic Renal Impairment, On 1.2 L fluid restriction
• Regular Medications: Bisoprolol 2.5 mg  mane; Furosemide 40 mg mane; Lipitor 40 mg nocte; olmetec 40mg nocte; digoxin 0.125 mg twice daily; Ivabradine 5 mg twice daily

Assement :

Airway :patent

Breathing :severe respiratory distress , respiration rate 38 breath per minute, SPO 98% non rebreather mask at 15 litre a minute, 86% room air, speaking short sentences, chest auscultation showed interiorly and posteriorly diffused crackles.

Circulation: Appears flushed and diaphoretic blood pressure 98/62,HR  83 beat per minute, dry mucus membrane, capillary refill less than two second, warm centrally, periphrases called to touch, pansystolic murmur on auscultation.

Disability :GCS 14 E4V 4M6, not orientated to time, place or person, Pearl 2 millimetre.

Exposure needed support to walk from waiting room to bed . temp 37.8 degrees Celsius , abdominal soft and tender RUQ. Pitting oedema .Right JVP pulsation

Fluid : unable to tolerate food nil by mouth for now

Glucose :14mmol/l

Investigation

• ECG- left bundle branch block
• CXR- consistent with fluid overload, cardiomegaly
• Troponin 5ng/dL
• Serum sodium 128 mmol/L, Potassium 5.8 mmol/L, GFR15mL/min, urea 9mmol/L, creatinine 155 mmol/L, WCC 7.8
• Additional information: Echocardiography showed a dilated heart (left ventricular end diastolic distension (LVEDD) 650 mm). The posterior wall was contracting vigorously. A high velocity jet (4.7 m s−1) of mitral regurgitation was noted but the left atrial size was normal.
• Diagnosis: Acute Pulmonary edema secondary to fluid overload on a background of congestive cardiac failure, chronic renal impairment
• A MET call was made at 0530hrs

using the rolfe model of reflection to answer the question below

Using evidence to identify a knowledge gap, propose a strategy to adopt that will assist you in future group presentations