1. Define all unknown terms.  Answer

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

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.   Answer

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

• Fatigue 

• Anorexia

• Exertional dyspnea

• Paroxysmal nocturnal dyspnea 

• Orthopnea

• Cough

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

• Patient’ appearance.

• The untied shoes

• Diaphoresis

• Labored breathing 

• Blue lips

• Cold hands

• Lowered BP

• Distended neck veins 

• Diminished S1 and S2 

• Holosytolic murmur

• S3

• Tachycardia

•  Irregular, irregular pulse

• Pulsus alternans

• Palpable liver edge

• Pitting edema

• Basal crackles

• Dullness in bases of lung fields

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

• Hemoglobin and hematocrit 

• Define azotemia and to explain what is meant by prerenal azotemia.

• Bilirubin and other Liver enzymes

• The electrolytes changes

• Specific gravity 

• Correlate the results of the chest x-ray (structural changes) with the clinical findings

7. What additional investigations are useful?  Answer

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

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?  Answer

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

10. Explain normal Starling curve  Answer

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?  Answer

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

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

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.  Answer

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?  Answer

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

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

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

• LV failure

• RV failure

• Low output failure

• High output failure

• Forward failure

• Backward failure

• Acute Heart failure

• Flash Pulmonary edema

• Chronic Heart failure

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

• Venous return

• Venous tone

• End diastolic pressure

• Stroke volume

• Heart rate

• Cardiac output

• Starling Curve

• Peripheral vascular resistance

• Autonomic nervous system regulation of CVS

• Wedge pressure

• Intravascular volume