Smith and Pat Sho

Question 1

Describe the presentation of heart failure (~35% of the total mark)

Answer 1

The most common symptom is breathlessness.

Orthopnoea (Breathlessness on lying flat) and less commonly paroxysmal nocturnal dyspnoea (waking up in the middle of the night)

Dry cough (pink frothy sputum - due to very significant fluid in lungs)

Fatigue, tiredness & confusion - lack of blood supply to the muscles and brains

Lack of appetite

Low mood

Swelling of the legs

Increased urination at night - usually due to medication

Question 2

Describe how you would conduct a heart failure examination (~35% of the total mark)

Answer 2

Can the patient walk up a flight of stairs?
Do you get breathless getting dressed?

Ask how many pillows they sleep on?

NYHA classification (1-4, description for higher marks)
Inspection - immediate observations, ascites (fluid in the stomach)

Palpation - feel for apex beat, legs (pitting oedema, when the indent stays), heart rate (high or low)

Percussion - dullness & signs of fluid in the lungs

Auscultation - listen for murmurs, S3 gallop (Kentucky)

NOTE: question asks for examination NOT investigations, so CXR, BNP, ECG do not gain any marks

Question 3

Describe the renal system involvement in heart failure (~15% of the total mark)

Answer 3

Reduced perfusion pressure in the glomeruli increased renin production, increased Na+ reabsorption

RAAS system - Ang-II vasoconstriction & cardiomegaly, Aldosterone - increase Na+ and water reabsorption

Question 4

Describe the heart failure treatment targeting the renal system (~15% of the total mark)

Answer 4

ACE inhibitors - reduce production of Ang-II (higher marks for examples, e.g. ~prils)

Ang-II receptor blockers (ARBs) - reduce actions of Ang-II (higher marks for examples e.g. ~sartans)

Aldosterone receptor antagonists - reduce actions of aldosterone (higher marks for example e.g. spironolactone, eplerenone)

Question 5

Describe the hypovolaemia/ dehydration signs (~30% of the total mark)

Answer 5

• Postural hypotension (mild dehydration)
• Arterial hypotension (moderate dehydration)
• Decreased jugular venous pressure
• Tachycardia
• Low skin turgor (also acceptable as symptom)
• Low urine output (oliguria)

Biochemistry for highest marks -
Serum osmolality high; Serum Na usually high; Serum urea high & Haemoglobin high

Question 6

Describe the hypovolaemia/ dehydration symptoms (~30% of the total mark)

Answer 6

Weight loss

Thirst (related to 1-2% weight loss)

Vague discomfort, loss of appetite (related to 2% weight loss)

Lethargy, apathy, nausea emotional instability (related to 3-4% weight loss)

Tingling limbs, heat exhaustion, increased body temp (related to 6% weight loss)

Dizziness, confusion, delirium (related to 8% weight loss)

Sunken eyes

Dry mouth

Diarrheoa

Question 7

Sepsis - hypovolaemia & one causative organism (20% of the total mark)

Answer 7

Increased capillary permeability due to sepsis and vasodilation

Gram positive organisms (e.g. S Aureus), Gram negative (e.g. E Coli, Neisseria, pseudomonas, klebsiella)

Question 8

What are the treatment options of this case?

NB: Case is patient suffering from hypovolaemia/dehydration

Answer 8

Replace fluids: IV normal saline; IV water with 5% dextrose; Water by mouth (to correct hypovolaemia)

Broad spectrum antibiotic (e.g. penicillin)