1. Define all unknown terms.  

2. Cite the primary clinical problem (not the diagnosis).  

3. Develop a differential diagnosis for this clinical problem on the basis of history. What is your diagnosis? Describe the data from the history which supports your diagnosis, keeping in mind the concepts of sensitivity, specificity, predictive value. Apply this strategy in ruling out other causes of the clinical problem.   

4. The diagnosis is congestive heart failure.   Speculate on the mechanism for the following historical information with the diagnosis of congestive heart failure  

5. In terms of the pathophysiology, explain the mechanism for the following physical findings:   

6. Correlate (explain) the laboratory data in terms of the diagnosis.  

7. What additional investigations are useful?  

8. What are compensatory attempts of the body to support failing heart: Which of these attempts are evident in Mr. Solomon?  

9. Which of the following drugs given intravenously would you expect to result in a rapid improvement in Mr. Solomon’s clinical condition? Which drugs would be expected to increase urine output?  

Amrione, Isoproterenol, Dobutamine, Dopamine, Exmolol, Norepinerphrine, Atropine, Furosemide, Nitroglycerine, Nitroprusside, Verapamil

10. Explain normal Starling curve  

11. Compared to normal, how do you think Mr. Solomon’s illness has altered his ventricular function curve (the relationship between LV end-diastolic and cardiac output)? Would his ventricular function curve be further altered by either digoxin, vasodilator therapy or diuretic therapy?   

12. What would be the most important concern in treating Mr. Solomon with a combination of digoxin and furosemide?  

13. How should Mr. Solomon’s daily dose of digoxin be adjusted depending on his serum creatinine levels?   

14. What would cause activation of the rennin-angiotensin system in Mr. Solomon and how would the administration of enalapril counteract those effects? Would enalapril lead to alterations in serum levels of any other peptide (in addition to Angiotensin II) that might have cardiovascular effects.  

15. After 6 months of treatment with digoxin, furosemide and enalapril, Mr. Solomon’s edema has resolved, but he continues to feel week and lethargic. Upon readmission to the hospital a catheter is placed into the right heart through a jugular vein and the following pressures are recorded: RA=6mmHg; PA-40/12mmHg; Wedge (mean)=12mmHg; cardiac output=3.5L/min. How should Mr. Solomon’s drug therapy be altered? 

16. What are the common etiologies for congestive heart failure? What is the most likely etiology of heart failure in Mr. Solomon?  

17. Let us summarize the therapeutic strategies to manage a patient in congestive heart failure?  

18 Let us understand few commonly used terms in relationship to Heart failure.  

19. Let us recall some of the concepts we learned in Function course and apply to our patient.