Cardiovascular Cases

Question 1

b/g cardiovascular risk factors – chronic kidney failure, long standing diabetes, diabetes and over 60y.o., age, male

• Sudden onset orthopnoea (breathless whilst lying down), episode of paroxysmal nocturnal dyspnoea, not responding to treatment
• Chest x-ray showing ? New congestive heart failure (i.e. acute pulmonary oedema)
• b/g COPD

1) What are the concerning features of this presentation?
2) What other questions would you ask this patient?
3) What physical examination findings might you find in congestive cardiac failure?
4) What do you think has happened to this patient?
5) What needs to happen now?

Answer 1

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1) What are the concerning features of this presentation?

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2) What other questions would you ask this patient?

1. Did you have chest pain?
2. • Other associated symptoms of heart attack – radiation of pain to jaw or arm, nausea/vomitting, diaphoresis (profuse sweating), dizzyness, palpitations
3. • Have you recently been unwell with respiratory symptoms such as runny nose, cough, sore throat, fever, loss of appetite?
4. • Thyroid symptoms – weight loss, anxiety, diarrhoea, palpitations, weakness (hyperthyroidism)

3) What physical examination findings might you find in congestive cardiac failure?

1. Abnormal heart rate/rhythm
   
   • • Tachycardia
   • • Irregularly irregular heart rate of atrial fibrillation• Bradychardia ?heart block
2. Low blood pressure
3. Elevated JVP
4. New heart murmur
5. Bibasal crackles
6. Bilateral pitting oedema

4) What do you think has happened to this patient?

n physical examination, there were some bibasal crepitations, otherwise normal

ECG – normal

Troponin (marker for heart attack) – in the thousands

Called patient at home and advised them to go to hospital. Wifecouldn’t drive so they called the ambulance, and I spoke theparamedics. I also called the hospital emergency admitting medical officer and faxed over the results

Within a week the patient had a CABG

Discharged a week later for cardiology follow up

5) What needs to happen now?

Question 2

• 36y.o. lady
• Previously recorded high blood pressure
• Unacceptably high blood pressure today
• Snoring - ?obstructive sleep apnoea
• Kidney damage – kidney failure on blood tests, leaking protein into urine
• Multiple joint pains – ?autoimmune process
• Non “compliant”

0. Questions
   1) What are the possible causes of the high blood pressure in her case?
   2) What needs to happen now?
   3) What are the long term management goals?

Answer 2

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1) What are the possible causes of the high blood pressure in her case?

• Hereditary (“essential”)
• Morbid obesity
• Current sore throat (pain)
• Overuse of nurofen
• Obstructive sleep apnoea
• Kidney disease – secondary cause of hypertension, with the proteinuria at the level of the glomeruli

2) What needs to happen now?

• She was sent to the emergency department for acute control of blood pressure
• She responded quickly to anti hypertensives
• She was referred on for renal review
• On further follow up her kidney function was deteriorating so they did a renal biopsy despite morbid obesity (difficult to perform)
• Kidney biopsy showed IgA nephropathy

3) What are the long term management goals?

• Patient understanding of severity of illness• Kidney protection
• • Avoid NSAIDs
• • Care with all medications taken/prescribed• ACE inhibitors to decrease proteinuria
• • Control BP
• • Healthy weight
• • Control cardiovascular risk factors• Address underlying sleep apnoea

Question 3

Cardiovascular exam

Answer 3