Information Sheet for Candidates Your next patient in a general practice is a 75 year old Mr.

Jones who is complaining about increasing shortness of breath on exertion over the last 4-5 months. e li!es to play golf but finds it more and more difficult to finish "# holes because he starts to huff and puff when he has to wal! long distances although it improves when he rests for a while. Your task is to: $a!e a focused history %xamine the patient &rgani'e appropriate investigations (iscuss your diagnosis and management with the patient

HOPC: )or the last 4-5 months Mr. Jones noticed some breathing difficulties when he wal!ed long distances and it started to interfere with his playing golf. More and more often he would have to stop to regain his breath* but it usually got better when rested for a little while. $he breathlessness seems to be getting worse. e also noticed that he had to use a couple of pillows at night time to avoid wa!ing up with shortage of breath and he gets up more often in the might to pass water. PHx.: Mr. Jones has been reasonably fit all his life. Moderate hypertension for about "5 years. as gained weight over the last ten years with +M, now -.. /ppendicectomy at age 0.* cholecystectomy 1age452* $345 1age 6#2. Med.: ta!es coverysl 1periindopril2 and betabloc!er for his hpt. FHx.:unremar!able SHx.: married* retired plumber* - children* no financial problems* has always li!ed his beer and drin!s about 4 stubbies every day* smo!es 0. cig.7 day 1-. years2* no allergies. EXAMINA ION: !"OO#$ "IS EN$ FEE" %%%%&: 8hubby loo!ing man with mild breathlessness when he wal!s into the consulting room* settling when he sits down. +M, -.9 :o cyanosis. +5 "657".5* 5 7. ;4 19<&= >&<3M%92* 44 0.* afebrile* ;a&0 ?4@ on 4/. 8>;A reduced carotid pulsation* diffuse apical impulse 1slightly laterali'ed to //< due to dilation of left ventricle2* ;"* ;0 and a presystolic 1fourth* atrial gallop2 heart sound as well as an early diastolic 1third2 heart sound can be identified* no murmurs. 4%;5,4/$&4YA few moist* fine* inspiratory crepitations over both basal lung fields with dullness on percussion. /+&M%:A hepatomegaly 10 cm2 )3:(,A /> nipping and Bsilver wiringC 1due to increased light reflex from thic!ened arterioles2 $he rest of the physical examination is normal. 'HA IS HE MOS "I#E"Y (IA)NOSIS*: CCF !+on,esti-e +ardia+ fai.ure%& Most li!ely secondary to hypertension and alcohol abuse. $his is the inability of the heart to pump sufficiently to provide the full metabolic demands of the tissues9 IN/ES I)A IONS: %8D 1left ventricular hypertrophy2 8E4Aalveolar infiltrates in affected lung fields* left ventricular enlargement* hilar congestion* upper lobe diversion with prominence of upper lobe blood vessels* increased vascular mar!ings* Ferley + lines 1G thin hori'ontal lines at the base of the lungfields due to dilated lymphatics secondary to elevated pulmonary venous pressure2 )+%* 3H%* <)$* glucose +:5 1brain-type natriuretic peptide2 5ossibly echocardiogram and eIection fraction measurement 1normal 65@2

MANA)EMEN : 54%>%:$,&:9 G identify the underlying causative factors and concentrate on the correction of these* e.g. hypertension* hypercholesterolaemia* alcohol* weight* control of diabetes* aggressive treatment of coronary syndrome7/M, 1thrombolysis* angioplasty* stenting* aspirin and beta-bloc!ers post infarction2 etc. <ife style changes G stop smo!ing* diet 1sodium and water restriction2 and weight reduction* stop alcohol* rest $reat underlying causes 1some already mentioned above92A /2 arrhythmias 1/)2 +2 electrolyte imbalance 1hypo!alaemia2 82 anaemia (2 , ( %2 dietary factors 1salt* alcohol* fat2 )2 drug reactions 1:;/,(s J fluidretention2 D2 infections 1pneumonia* endocarditis2 2 thyrotoxicosis 85/5 (rug $herapyA ".2 (iuretics 1)rusemide2 0.2 /8% inhibitors -.2 +eta-bloc!ers 4.2 (igoxin PHYSIO"O)Y: ". 8/4(,/8 &3$53$ G heart rate x stro!e volume 17. mls at rest2 G 5.5 <7min eIection fraction 65@ 0. 54%<&/(A length of myocardial fibre at onset of systole 1or end of diastole2K this is eLuivalent to the end diastolic volume of the ventricle 1"-. mls2K )4/:F J ;$/4<,:DM law -. /)$%4<&/(A the total load against which the heart must contractK is determined by systemic vascular resistance and aortic complianceK the capacity of the muscle to perform wor! independent of the other two factors 1sympathetic stimuli* hypoxia* negative inotropes* acidosis* myocardial damage2

4. 8&:$4/8$,<,$YA

C"ASSIFICA ION OF SE/E0I Y 1 NYHA !Ne2 York Heart Asso+iation&: ,. symptoms on abnormal exertion ,,. symptoms on ordinary activity ,,,. symptoms on less than usual activity ,>. symptoms at rest