HYHO I -- Heart Failure

Question 1

You have a patient that comes in with a history of a previous MI, LVH and a low EF. At the present moment they have no present symptoms of Heart Failure.

What Stage is the person presenting with?

Answer 1

Stage B

Question 2

You have a patient that comes in with a history of a previous MI, LVH and a low EF. At the present moment they have no present symptoms of Heart Failure.

If this person had no structural deficits and no symptoms what stage would this patient be at?

Answer 2

Stage A

Question 3

2 years later, the same patient as before comes into your clinic, their previous MI and LVH is now causing this shortness of breath, a Low O2 sat, and is causing them signifcant fatigue.

What is their current Stage?

If this person were noted to have marked symptoms even at rest – what stage?

Answer 3

Stage C

Stage D

Question 4

You have a patient that comes into your clinic with what you think is heart failure. You measure their ejection fracture and find that their ejection fracture is 48%.

How would we classify this patient?

Answer 4

Borderline Reduced Ejection Fracture

Question 5

You have a patient that comes into your clinic with what you think is heart failure. You measure their ejection fracture and find that their ejection fracture is 48%.

The same patient is now categorized as heart failure, but is measured 3 hours later and their ejection fracture has improved to 56% – how would we classify this now?

Answer 5

Heart Failure with perserved Ejection Fracture

Question 6

Your attending is worried about the risk of one of your patients for heart failure. He wants to know the main problems that would cause this patient to be at a higher risk for HF – what would you tell him?

Answer 6

Age – +65

M > W (but women are more commonly seen, b/c they live longer)

1 in 5 people over the age of 40 develop heart failure in their lifetime. (in North America)

Question 7

You have a patient that has marked limitation of physical activity from their previous MI. They state that they are comfortable at rest, but just walking around makes them breathless. They have generalized fatigue, and complain of what feels like their heart racing and chest pounding when they mildly exert themselves.

What is their NYHA Class level?

Explain how the patient could change levels (describe the other levels)

Answer 7

Class III

Question 8

You have a patient that comes into your clinic with heart problems, and upon ausculatation you hear what sounds like an opening snap during systole, and a palpable S1. The duration of this murmur is longer and more severe. You seem to hear the rest of the murmur best during diastole.

What is the underlying condition?

What normally causes this?

Answer 8

Mitral Stenosis

Rheumatic Fever (most of the time)

Question 9

You have a patient that comes into your clinic with “heart problems”. You listen to their heart sounds and find a blowing, holosystolic murmur that is best heard in systole. She has been complaining of fatigue, weakness, and exertional dyspnea. You also notice that there is splitting of the S2 and S3.

What is the problem?

What causes this problem?

Answer 9

Mitral Regurg

Rheumatic HDz, MVP, Ischemic Heart Dz with papillary muscle dysfunction

Question 10

You have a patient that comes in with chest pain, you hear a harsh sound at their right top chest, (near their clavicle). You notice that the sound seems to radiate to the suprasternal notch and their carotids.

What type of murmur causes this?

What is associated with it?

Answer 10

Aortic Stenosis

Aortic Calcific Stenosis main cause

Question 11

Another patient comes into your clinic with complaints of exertional dyspnea and they’ve been noticing they feel their heartbeat. You decide to listen with your diaphragm and hear a blowing decrescendo murmur on the left side of his chest, near the clavicle.

What is the murmur?

What is this associated with?

Answer 11

Aortic Regurg (Diastolic Murmur)

Rheumatic Etiology, Infective Endocarditis, Syphilis,

Question 12

You have a patient that shows up with a blowing quality murmur, and on inspiration you notice that it gets louder. It is holosystolic.

What is the problem?

Where would this be heard best?

Answer 12

Tricuspid Insufficiency (Systolic murmur)

Lower LEFT Sternal Border

Question 13

You have a patient that comes in Hepatomegaly, ascites, edema – and a diastolic rumbling murmur along the left sternal border. You notice that it is increased by inspiration. You have her breath out anbd notice that it decreases in instensity; to confirm you have her perform a valsalva manuever.

What is the problem?

What is associated with this?

Answer 13

Tricuspid Stenosis (Diastolic)

Usually Rheumatic – also associated with Mitral Stenosis

Question 14

You have a patient that comes in with heart failure, and you want to check their right atrial pressure: so you perform a measurement of her Jugular Venous Pressure. Which of the following is NOT the correct method – and how would you fix it?

A. You need to Focus on the Right Internal Jugular V

B. Raise the head to about 30 degrees, and turn the patients head slightly AWAY from you

C. Identify the highest point of pulsation in the right jugular V

D. The Sum of the JVP is the measurement of the vertical distance above the sternal angle and where the object crosses the ruler (and add 5 cm)

Answer 14

None of these are incorrect

(you medical students always are trying to find whats wrong . . . look at the happy side of life)

Question 15

You have a patient that is presenting with heart failure with a perserved EF. You would expect what diagnostic data to be found? And what tests would be done to confirm?

Answer 15

Beta Natrietic Peptide would be elevated (although would be lesser than someone who has a worse EF)

Cardiac Enzymes (Troponin I/T, CKMB)

You would need a CBC, CMP, UA, Echocardiography with Doppler, Chest Radiography, EKG etc.

Question 16

A patient comes in that complains of substernal pain – after taking an exceptional history, hanging up a poster of a friendly birracial couple, and coming up with a differential diagnosis – you decide to order a chest x-ray.

What are the steps of exaiming a chest x-ray?

Answer 16

A - Airways

B - Bones

C - Cardiac

D - Diaphragm

E- Everything Else

F - Fields of the lung

Question 17

A patient comes in that complains of substernal pain – after taking an exceptional history: (the patient has LE edema, a night cough, and a fast heart rate) hanging up a poster of a friendly birracial couple (you are welcome Dr. Joy), and coming up with a differential diagnosis – you decide to order a chest x-ray.

You notice the following: The patient has a midline trachea, they have no broken bones, with slight internal rotation of their clavicle, the heart looks enlarged, Diaphragm is normal, and evidence of pulmonary edema. The rest of your tests, point you toward the diagnosis of heart failure. According to the Framingham Criteria, what major criteria need to be found to confirm? (and what criteria from your examination fits this?)

Answer 17

Major: Paroxysmal Nocturnal Dyspnea

Orthopnea

Elevated JVP

3rd Heart Sound

Radiological evidence of Cardiomegaly *

Radiological evidence of Pulmonary Edema *

Minor: Extremity Edema *

Night Cough *

Hepatomegaly

Heart Rate >120 *

Exterional Dyspnea

Pleural Effusion

This patient overqualifies for Heart Failure due to Framingham Criteria

Question 18

You have a patient that has an ejection fracture of 65% what type of heart failure are they more likely to have?

What other considerations do I need to consider for this patient?

Answer 18

Diastolic Heart Failure ( b/c EF > 50)

(Systolic would be less than 50)

Consider Coronary A Dz!

Question 19

You are a genius KCU student who has just examined their first patient on IM rotations. The Patient came into your clinic complaing of a tiredness and fatigue that began quickly and has progressed relentlessly for 4 weeks. You want to consider every possible avenue: What are some considerations of DDx in this patient?

Answer 19

Anemia, Pleural Effusion, Respiratory NM Disorders

Question 20

You are a genius KCU student who has just examined their first patient on IM rotations. The patient came into your clinic with an acute onset of tiredness and fatigue and has progressed over the last few minutes to being worse. What are some possible DDx?

Answer 20

Pulmonary Thromboembolism

Pneumothorax

LV Failure

Asthma

Inhaled Foregin Body

Question 21

You are a genius KCU student who has just examined their first patient on IM rotations. The patient came in with complaints of weakness and fatigue that came on gradually and has been getting worse for the past 3 days. What are some DDx?

Answer 21

Pneumonia

Asthma

Exacerbation of COPD

Question 22

You are a genius KCU student who has just examined their first patient on IM rotations. You have a patient that came into your clinic complaining of a gradual onset of dyspnea and faituge that has been getting worse over the past 3 years. What is in your DDx?

Answer 22

COPD

Pulmonary Fibrosis

Pulmonary Tuberculosis

Question 23

You have a patient that had Heart Failure with reduced Ejection Fraction that is being discharged. You recall the goals of treatment that this patient needed because you have a new patient that has come in looking like a similar case: What are the goals of therapy?

Answer 23

Reduce Mortality

Reducing Symptoms

Improving Health-Related QoL

Lifestyle Mods (Smoking Cessation, Healthy Eating, Losing Weight etc)

Pharmacological Mods (ACEi, ARBs, Hydralazine, Digoxin, etc)

OMM considerations

Question 24

You have a patient that had Heart Failure with PERSERVED Ejection Fraction that is being discharged. You recall the goals of treatment that this patient needed because you have a new patient that has come in looking like a similar case: What are the goals of therapy?

Answer 24

To Treat the underlying diseases

HTN, Diabetes, Hyperlididemia, A Fib, etc.

Question 25

You have a patient on a diuretic after a diagnosis of heart failure – what is the goal of Diuretics in this state?

What about Beta Blockers?

ACEi?

Answer 25

Diuretics: To treat volume overload, and decrease the pre-load on the heart.

BB: Not great for HF with perserved EF (unless angina present), normally given within 1 day of an MI to help reduce myocardial contractility.

ACEi: Helps to improve myocardial EF if administered within 1-16 days from an MI.

Question 26

You have a patient that has Heart Failure with Reduced Ejection Fraction (HFrEF).

What is the first line therapy you need to offer this patient?

If the patient reports a cough or shows signs of tongue swelling with a ACEi – what can you move too?

Answer 26

ACEi and BB’s

ARB’s and BB

Question 27

You have a patient that has Heart Failure with Reduced Ejection Fraction (HFrEF).

This patient is intolerant to both ACEi and ARB’s what is the next best mode of treatment?

Last case scenario if all prior treatments dont seem to be improving?

Answer 27

Hydralazine and Nitrates

• (Any of these)*
  1) Replace ACEi with Sacubitril Valsartan
  2) Add Ivabradine if in sinus rhythm
  3) Add Hydralazine and Nitrate (if AA or Caribbean)
  4) Digoxin for worsening HF

Question 28

For all heart failure patients we need to offer what to the patient, because we are Osteopathic Physicians?

Answer 28

A Personalized, Excersize based cardiac rehabilitation programme, (unless they are unstable)

also OMM . . . .sure.

Question 29

Jerry comes in with heart failure. He almost dies, luckily you save him. Out of sheer respect and thanks, he listens to you (instead of his wife Doreen) and lets you perfom some OMM on him.

What sort of Neurological Components to the OMM considerations do we need to consider on this patient?

Answer 29

Parasympathetic Activation: working on the Vagus N, OA, AA, C2

Sympathetic: T1-T5

Motor: C3-C5 phrenic nerve to the diaphragm

Question 30

Jerry comes in with heart failure. He almost dies, luckily you save him. Out of sheer respect and thanks, he listens to you (instead of his wife Doreen) and lets you perfom some OMM on him.

What sort of tenderpoints would you find in this patient?

Answer 30

Tissue Texture Changes over Cervical Pillars/ Thoracic TP

Rotated Cervical and Thoracic Vertebrea

Compression of Occipitomastoid sutures and Occipito-Atlantoid Joint

Question 31

Jerry comes in with heart failure. He almost dies, luckily you save him. Out of sheer respect and thanks, he listens to you (instead of his wife Doreen) and lets you perfom some OMM on him.

What other somatic dysfunctions would you presume Jerry would have?

Answer 31

Extremity Edema (fix with Efflurage and Petressage)

Rib Dysfxn (fix with HVLA, ME, MFR etc)

Flattened Diaphragm (help with Doming the Diaphragm etc)

Scalene/Pec Minor Hypertonicity and TP (fix with MFR, Soft Tissue)

Question 32

Jerry comes in with heart failure. He almost dies, luckily you save him. Out of sheer respect and thanks, he listens to you (instead of his wife Doreen) and lets you perfom some OMM on him.

Doreen says that she wants to go home now, and doesnt want Jerry to have a very long treatment process. What would be something you could do quiclky to help Jerry along.

Answer 32

Give him the number of a good divorice attorney . . .

Pedal Pump – to help with his LE edema

Question 33

Jerry comes in with heart failure. He almost dies, luckily you save him. Out of sheer respect and thanks, he listens to you (instead of his wife Doreen) and lets you perfom some OMM on him.

After some convicing, Doreen agrees to 5 mins. She wants it done quickly though as Bold and the Beautiful starts soon – and Jerry made her miss last weeks episode. What would you help him with now?

Answer 33

Potentially Pedal pump still,

BUT mainly RIB RAISING

Question 34

Jerry comes in with heart failure. He almost dies, luckily you save him. Out of sheer respect and thanks, he listens to you (instead of his wife Doreen) and lets you perfom some OMM on him.

Jerry tells Doreen to go on home, and he will take an Uber home. You can do a full OS treatment on him – what are some considerations for him?

Answer 34

Question 35

Jerry comes in with heart failure. He almost dies, luckily you save him. Out of sheer respect and thanks, he listens to you (instead of his wife Doreen) and lets you perfom some OMM on him.

Lastly before Jerry leaves, you want to help him with his long-term complications: What are some considerations to consider?

Answer 35

Offer both: ACEi, and BB for heat failure as first line tx.

if his symptoms persist –

1) An Aldosterone Antag. (if severe heart failure)
2) ARB (if mild to moderate HF)
3) Hydralazine with Nitrate (for AA or Carribean)

Help him with any other lifestyle mods and other associated diseases that can cause future trouble – and maybe talk to him about how his home life is. . .

Question 36

You have a patient that is presenting with Heart Failure. What sort of tests would you like to run to help narrow your differential dx?

Answer 36

CBC

CMP

ECG

Chest XRay

Bedside Echocardiography

Liver Fxn Tests

Question 37

You heart failure patient is presenting with an SpO2 of 85, edema, and a rapid heart rate. You note that they have ADHF. What are some rapid treatment options to consider for this patient?

you later notice that they have an ascending aortic dissection – what is needed now?

Answer 37

Supplemental O2

NIV prn (with airway management equipment on standby)

Diuretic Therapy (Furosemide/Torsemide)

Digoxin (to slow their HR)

** Consult Cardiac Surgery **

Question 38

Your heart failure patient that you just saw and put on furosemide is still having congestion and fluid overload. What is the next option to help this patient?

Answer 38

Give a vasodilator:

IV Nitroglycerin with Diuretic therapy to reduce preload.

Question 39

You heart failure patient has a low EF (Systolic HF) and has severe ADHF and cardiogenic shock. What is the best treatment modality now?

What is this patient had had Perserved EF (Diastolic HF) and had ADHF and cardiogenic shock?

Answer 39

IV Inotrope (Dobutamine, Milrinone) and mechanical support (Intraaortic Balloon Counter pulsation)

Treat with BB, IV Fluid, and IV Vasopressor (phenylephrine/NE) – DO NOT GIVE INOTROPE OR VASODILATOR to Diastolic HF **

Question 40

You heart failure patient still has an unknown cardiac status but has signs of ADHF (ie. pulmonary edema) and hypotension and signs of shock. What is the best tx modality?

Answer 40

IV Inotrope (Dobutamine, Milrinone) with or without a Vasopressor (NE) might need mechanical support.