MBBS QUESTION ANSWER CARDIOLOGY IHD HF.pdf

Professor DR Md . TOUFIQUR RAHMAN , FCPS, MD
Professor & Head, Cardiology, CMMC, Manikganj
drtoufiq19711@yahoo.com; drtoufiq1971@gmail.com
What is the clinical importance of auscultating the precordium?
Auscultation of the precordium, which is the area of the chest overlying the heart, is an essential
component of the cardiac examination. The clinical importance of auscultating the precordium includes:
 Assessment of heart sounds: Auscultation can help identify the presence of abnormal heart
sounds such as murmurs, gallops, and clicks. These sounds may indicate structural
abnormalities of the heart valves or other cardiac structures.
 Diagnosis of arrhythmias: The timing and character of heart sounds can also provide clues
about the presence of arrhythmias such as atrial fibrillation or ventricular tachycardia.
 Evaluation of cardiac function: The intensity of heart sounds and the presence of additional
sounds, such as a third or fourth heart sound, can provide information about the overall
function of the heart.
 Detection of pericardial effusion: Auscultation can help identify the presence of a pericardial
effusion, which is the accumulation of fluid around the heart.
 Monitoring of cardiac interventions: Auscultation can be used to monitor the effectiveness
of medical or surgical interventions on the heart.
Overall, auscultation of the precordium is an important component of the cardiac examination and can
provide valuable diagnostic and prognostic information about a patient's cardiovascular health.
Enumerate the types of cardiac apical impulse with example
Normal apical impulse:
The normal apical impulse is described as a brief, tapping, and low-pitched sensation felt at the 5th
intercostal space in the midclavicular line. It has a duration of less than 0.16 seconds and an amplitude
of less than 2.5 cm. This is considered a normal finding and represents the left ventricular impulse.
Displaced apical impulse:
A displaced apical impulse refers to a sensation felt at a location other than the normal 5th intercostal
space in the midclavicular line. This finding can be indicative of left ventricular hypertrophy, left atrial
enlargement, or pericardial effusion. For example, in left ventricular hypertrophy, the apical impulse is
felt at a more lateral location in the 6th or 7th intercostal space, while in pericardial effusion, the apical
impulse may be difficult to palpate due to the accumulation of fluid around the heart.
Hyperdynamic impulse: A forceful and sustained apical impulse that is typically seen in conditions
such as hyperthyroidism or anemia.

Heaving impulse: A slow-rising, sustained apical impulse that may be seen in conditions such as aortic
stenosis or hypertrophic cardiomyopathy.
Tapping impulse: A sharp, brief apical impulse that is felt during the first half of systole and may be
seen in conditions such as mitral stenosis or aortic regurgitation.
Displaced impulse: An apical impulse that is felt in a location other than the normal fifth intercostal
space, midclavicular line. This may be seen in conditions such as left ventricular hypertrophy or
cardiac tamponade.
Diffuse impulse: An apical impulse that is felt over a wider area than normal, indicating enlargement
of the heart. This may be seen in conditions such as dilated cardiomyopathy or chronic severe mitral
regurgitation.
What are the causes of shifted cardiac impulse ?
Shifted cardiac impulse or displaced cardiac impulse is a clinical finding in which the cardiac apex is
located outside the normal location. It may occur due to various causes, including:
 Left ventricular hypertrophy: A thickening of the left ventricle of the heart, commonly seen
in conditions like hypertension and aortic stenosis.
 Dilated cardiomyopathy: A condition in which the heart becomes enlarged and weakened,
leading to heart failure.
 Constrictive pericarditis: Inflammation and scarring of the pericardium (outer layer of the
heart) leading to restricted movement of the heart.
 Tension pneumothorax: A condition in which air accumulates in the pleural cavity and
compresses the heart leading to a shift in its position.
 Large pleural effusion: An accumulation of fluid in the pleural cavity which can compress
the heart leading to its displacement.
 Massive ascites: Accumulation of fluid in the abdomen which can push the diaphragm
upwards leading to the heart's upward displacement.
 Pregnancy: As the uterus enlarges during pregnancy, it can displace the heart to a more
superior position.

These are some of the common causes of a displaced cardiac impulse. It is important to identify the
underlying cause of a displaced cardiac impulse as it can provide valuable diagnostic information and
guide appropriate management.
What are the causes of non-palpable apex beat?
The causes of non-palpable apex beat may include:
 Obesity: In obese individuals, the adipose tissue can mask the apex beat.
 Emphysema: In individuals with emphysema, the lungs can become hyperinflated, pushing
the heart deeper into the chest and making the apex beat difficult to palpate.
 Pericardial effusion: In cases of pericardial effusion, the accumulation of fluid in the
pericardial sac can compress the heart and make the apex beat non-palpable.
 Aortic aneurysm: Aortic aneurysm can displace the heart and make the apex beat non-
palpable.
 Cardiomyopathy: In some types of cardiomyopathy, such as hypertrophic cardiomyopathy,
the hypertrophied muscle can make it difficult to palpate the apex beat.
It is important to note that in some cases, the apex beat may be palpable but difficult to locate due to its
displacement. In such cases, further evaluation, such as imaging studies, may be needed to locate the
apex beat.
What are the causes of non palpable cardiac impulse in the left side of
the chest?
The causes of a non-palpable cardiac impulse in the left side of the chest can include:
 Obesity: In obese patients, it may be difficult to palpate the cardiac impulse due to the thick
layer of subcutaneous fat.
 Chronic Obstructive Pulmonary Disease (COPD): Patients with severe COPD may develop
hyperinflated lungs, causing the heart to be displaced downwards and to the right. This can
make it difficult to palpate the cardiac impulse.
 Pericardial effusion: An accumulation of fluid in the pericardial sac can cause the heart to be
compressed and displaced, making the cardiac impulse difficult to palpate.

 Emphysema: Emphysema can cause hyperinflation of the lungs and result in a flattened
diaphragm, which can displace the heart downwards and to the right.
 Dilated cardiomyopathy: In dilated cardiomyopathy, the heart becomes enlarged and
weakened, which can make it difficult to feel the cardiac impulse.
 Congenital heart disease: Certain congenital heart defects can cause the heart to be displaced,
making it difficult to palpate the cardiac impulse.
Short note : Echocardiography
Echocardiography is a non-invasive diagnostic test that uses ultrasound waves to create images of the
heart's structures and function. It is commonly used to assess the heart's size, shape, and pumping
function, as well as the function of the heart valves and blood vessels.
Echocardiography is performed using a handheld device called a transducer that is placed on the
patient's chest. The transducer emits high-frequency sound waves that bounce off the heart's structures
and are picked up by the transducer. These sound waves are then converted into images on a computer
screen.
Echocardiography is a useful tool in the diagnosis and management of many heart conditions, including:
Congenital heart defects
Valvular heart disease
Cardiomyopathies
Pericardial disease
Aortic aneurysms and dissections
Heart failure
Endocarditis
Echocardiography is a safe and non-invasive procedure that does not use ionizing radiation. It can be
performed in a doctor's office, hospital, or imaging center and typically takes less than an hour to
complete.
Short note : Echocardiography
Echocardiography is a non-invasive medical test that utilizes high-frequency sound waves
to create images of the heart. Here are some points about echocardiography:
 It is a commonly used diagnostic tool in cardiology.

 Echocardiography can provide detailed information about the size, shape,
function, and motion of the heart's chambers and valves.
 It can be used to detect various heart conditions such as valve disorders, heart
failure, congenital heart defects, and pericardial diseases.
 There are several types of echocardiography, including transthoracic
echocardiography (TTE), transesophageal echocardiography (TEE), stress
echocardiography, and 3D echocardiography.
 TTE is the most commonly used type of echocardiography, which uses a
transducer placed on the chest to produce images of the heart.
 TEE involves inserting a specialized probe down the patient's esophagus to obtain
images of the heart that are more detailed than those obtained with TTE.
 Stress echocardiography involves exercising the heart to evaluate its function
under stress conditions, which can help diagnose coronary artery disease.
 3D echocardiography provides a more detailed, real-time view of the heart's
anatomy and function, allowing for more accurate diagnosis and treatment
planning.
 Echocardiography is safe and does not involve radiation exposure or other
harmful side effects.
Mention the important causes of chest pain
There are several important causes of chest pain, including:
 Angina: This is a type of chest pain caused by a reduced blood flow to the heart
muscle due to narrowing of the coronary arteries.
 Myocardial infarction (heart attack): This occurs when a blood clot blocks the
blood flow to the heart, causing damage to the heart muscle.
 Pulmonary embolism: This is a blockage in the lung arteries caused by a blood clot
that has traveled from another part of the body.
 Pneumonia: This is an infection of the lungs that can cause chest pain, cough, and
fever.

 Gastrointestinal problems: These can include gastroesophageal reflux disease
(GERD), peptic ulcer disease, or inflammation of the gallbladder or pancreas.
 Musculoskeletal problems: These can include costochondritis (inflammation of the
cartilage that connects the ribs to the breastbone) or a muscle strain or sprain in the
chest area.
 Anxiety or panic attacks: These can cause chest pain or discomfort, along with
other symptoms such as shortness of breath, sweating, and palpitations.
How would you differentiate cardiac chest pain from non
cardiac chest pain?
Differentiating cardiac chest pain from non-cardiac chest pain can be challenging, but certain
clinical features and diagnostic tests can aid in distinguishing the two. Here are some ways to
differentiate cardiac chest pain from non-cardiac chest pain:
 Onset: Cardiac chest pain often starts suddenly, whereas non-cardiac chest pain may
develop more gradually over time.
 Location: Cardiac chest pain is usually located in the center of the chest or the left
side, while non-cardiac chest pain may be more diffuse and located in different areas
of the chest.
 Quality: Cardiac chest pain is typically described as a pressure or squeezing
sensation, whereas non-cardiac chest pain may be sharp, burning, or stabbing.
 Radiation: Cardiac chest pain may radiate to the left arm, neck, jaw, or back, while
non-cardiac chest pain may not have any radiation or may radiate to other areas such
as the upper abdomen.
 Associated symptoms: Cardiac chest pain is often accompanied by shortness of
breath, sweating, nausea, or dizziness, while non-cardiac chest pain may be
associated with symptoms such as coughing, wheezing, or difficulty swallowing.

Diagnostic tests that can help differentiate between cardiac and non-cardiac chest pain include
electrocardiogram (ECG), cardiac biomarkers, stress testing, and imaging tests such as
echocardiography or computed tomography (CT) scan. It is important to seek medical
attention promptly for any chest pain, as it can be a sign of a serious condition.
How can you differentiate cardiac from non cardiac chest pain,
clinically?
Differentiating cardiac chest pain from non-cardiac chest pain is crucial in clinical practice. Here are
some clinical features that can help differentiate the two:
Cardiac chest pain:
 Typically, it is described as a squeezing, pressure-like, or heaviness sensation in the chest.
 It may radiate to the left arm, shoulder, neck, jaw, or back.
 Often, it is associated with shortness of breath, sweating, nausea, and dizziness.
 It is usually provoked by exertion or emotional stress and relieved by rest or nitroglycerin.
 Patients with cardiac chest pain may have a history of cardiovascular disease or risk factors
for it, such as hypertension, diabetes, or smoking.
Non-cardiac chest pain:
 It is often described as sharp, stabbing, or burning pain in the chest.
 It may be localized to a specific area or diffuse.
 It may be associated with musculoskeletal or gastrointestinal symptoms, such as chest wall
tenderness, dysphagia, or reflux.
 It is usually not provoked by exertion or emotional stress and not relieved by nitroglycerin.
 Patients with non-cardiac chest pain may have a history of anxiety or depression, respiratory
disease, or gastrointestinal disorders.
However, it is important to note that these clinical features are not always specific, and some patients
may have atypical presentations. Therefore, a comprehensive evaluation, including a detailed history,
physical examination, and appropriate diagnostic testing, is necessary to establish a diagnosis and rule
out serious conditions.
How can you differentiate between ischemic chest pain and non cardiac
chest pain?
Ischemic chest pain, also known as angina, is a type of chest pain that occurs due to inadequate blood
supply to the heart muscles. Non-cardiac chest pain, on the other hand, is chest pain that is not related
to the heart.

There are several ways to differentiate between ischemic chest pain and non-cardiac chest pain:
 Location: Ischemic chest pain typically occurs in the center of the chest or in the left side of
the chest. Non-cardiac chest pain may be located in different areas of the chest.
 Radiation: Ischemic chest pain may radiate to the neck, jaw, shoulders, arms, or back. Non-
cardiac chest pain may not radiate to other parts of the body.
 Duration: Ischemic chest pain usually lasts for a few minutes and is relieved by rest or
nitroglycerin. Non-cardiac chest pain may last longer and may not be relieved by rest or
nitroglycerin.
 Trigger: Ischemic chest pain may be triggered by physical activity, emotional stress, or a
heavy meal. Non-cardiac chest pain may not be related to any specific trigger.
 Associated symptoms: Ischemic chest pain may be associated with symptoms such as
shortness of breath, sweating, and nausea. Non-cardiac chest pain may not be associated with
these symptoms.
It is important to differentiate between ischemic chest pain and non-cardiac chest pain as their
management strategies are different. Ischemic chest pain requires immediate medical attention, while
non-cardiac chest pain may be managed conservatively with lifestyle modifications and medications.
How would you differentiate chest pain of angina pectoris from that of
acute myocardial infarction? (DU- 19Nov)
Angina pectoris and acute myocardial infarction (AMI) both present with chest pain but have some
distinguishing features.
Angina pectoris:
 Chest pain is usually described as a pressure or squeezing sensation, often retrosternal in
location.
 Pain is usually relieved by rest or nitroglycerin.
 Pain typically lasts for a few minutes (2-5 minutes).
 Electrocardiogram (ECG) may show ST-segment depression or T-wave inversion.
 Cardiac biomarkers (troponin, CK-MB) are typically normal.
Acute myocardial infarction:

Chest pain is usually more severe and prolonged, often described as a crushing or burning
sensation.
Pain is not relieved by rest or nitroglycerin.
Pain lasts for more than 30 minutes, and may be associated with other symptoms such as
shortness of breath, diaphoresis (excessive sweating), nausea, or vomiting.
ECG may show ST-segment elevation or Q-waves in the affected leads.
Cardiac biomarkers (troponin, CK-MB) are elevated.
It is important to note that there can be overlap in the presentation of angina pectoris and AMI,
and that a definitive diagnosis requires further testing such as cardiac imaging or angiography.
A 35 years old lady has orthopnoea. What may be the causes? How will
you manage her?(DU-08M)
Orthopnea refers to shortness of breath that occurs when lying down and is relieved by sitting up or
standing. It can be caused by various underlying conditions.
Possible causes of orthopnea include:
Heart failure: A weakened heart may not be able to pump blood effectively, leading to fluid
accumulation in the lungs and causing difficulty breathing while lying down.
Asthma: Inflammation and narrowing of the airways can make it difficult to breathe when
lying down.
Chronic obstructive pulmonary disease (COPD): This progressive lung disease makes it
difficult to breathe due to damage to the air sacs in the lungs.
Obesity: Excess weight can put pressure on the chest and lungs, making it difficult to breathe
when lying down.
Gastroesophageal reflux disease (GERD): Acid reflux can worsen when lying down,
leading to symptoms such as coughing and difficulty breathing.
Sleep apnea: This condition causes brief interruptions in breathing during sleep, which can
worsen when lying down.
Anxiety or panic disorders: These conditions can cause difficulty breathing, particularly
when lying down.

To manage a patient with orthopnea, it is important to identify and treat the underlying cause. A
thorough history and physical examination, as well as appropriate diagnostic tests, such as chest X-ray,
electrocardiogram (ECG), echocardiography, pulmonary function tests, or sleep studies, may be
necessary to determine the underlying cause.
Treatment will depend on the cause of orthopnea, but may include:
Medications such as diuretics to remove excess fluid in the lungs, bronchodilators to open up
the airways, or proton pump inhibitors to reduce acid reflux.
Oxygen therapy to improve breathing.
Lifestyle changes such as weight loss, smoking cessation, and avoiding lying flat.
Treatment of underlying conditions such as heart failure or COPD.
In some cases, surgery may be necessary to correct structural abnormalities that are causing
orthopnea.
It is important to closely monitor the patient's symptoms and response to treatment and make
appropriate adjustments as needed.
What are the causes of dizziness or vertigo in old age?
Dizziness or vertigo is a common problem among older adults and may have several causes. Some of
the common causes of dizziness or vertigo in old age are:
Benign paroxysmal positional vertigo (BPPV): It is a common cause of vertigo in older
adults, characterized by a sudden onset of dizziness or spinning sensation upon movement of
the head.
Meniere's disease: It is a disorder of the inner ear that can cause vertigo, hearing loss, and
ringing in the ears (tinnitus).
Vestibular neuritis: It is an inflammation of the vestibular nerve that can cause vertigo,
dizziness, and balance problems.
Stroke: A stroke can cause dizziness or vertigo, especially if it affects the part of the brain
that controls balance.

Medications: Some medications can cause dizziness or vertigo as a side effect, especially in
older adults who may be taking multiple medications.
The management of dizziness or vertigo in older adults depends on the underlying cause. Treatment
may include medications, vestibular rehabilitation therapy, or surgery in some cases. It is important to
seek medical attention if you are experiencing dizziness or vertigo, as it can be a sign of a serious
underlying condition.
Write down the clinical features of left ventricular failure. (DU- 20M,
17/16Ju)
Left ventricular failure occurs when the left ventricle of the heart fails to pump blood effectively to the
rest of the body. The clinical features of left ventricular failure may include:
Dyspnea: This is a common symptom in patients with left ventricular failure. It may be
present during rest or on exertion and may be associated with paroxysmal nocturnal dyspnea.
Orthopnea: Patients may experience difficulty breathing when lying flat and may need to
prop themselves up with pillows to sleep.
Fatigue: Patients may feel fatigued and weak due to poor blood supply to the muscles and
organs.
Edema: Fluid accumulation in the lungs or other parts of the body may lead to swelling or
edema.
Cyanosis: In severe cases of left ventricular failure, there may be a bluish discoloration of the
skin and mucous membranes due to poor oxygenation of the blood.
Tachycardia: Patients may experience an increased heart rate due to the body's attempt to
compensate for poor cardiac output.
Crackles: Lung examination may reveal crackles or rales due to the presence of fluid in the
lungs.
Reduced urine output: Patients may experience reduced urine output due to poor blood flow
to the kidneys.

Enlarged liver: Liver enlargement may occur due to congestion and passive congestion.
Management of left ventricular failure involves treating the underlying cause and managing the
symptoms. Treatment may include medications such as diuretics, ACE inhibitors, and beta-blockers, as
well as lifestyle changes such as limiting salt intake, reducing alcohol consumption, and engaging in
regular exercise. In severe cases, hospitalization and additional interventions such as mechanical
ventilation, inotropic support, or even heart transplant may be required.
Write down the clinical features and management of acute left heart
failure. (DU-09Ja)
Acute left heart failure, also known as acute pulmonary edema, is a medical emergency that requires
prompt diagnosis and management. The clinical features and management of acute left heart failure are
as follows:
Clinical features:
Sudden onset of severe dyspnea or shortness of breath
Orthopnea (difficulty breathing while lying flat)
Paroxysmal nocturnal dyspnea (awakening from sleep with shortness of breath)
Pink frothy sputum or coughing up blood
Chest pain or discomfort
Rapid breathing and heart rate
Sweating and anxiety
Cyanosis (bluish discoloration of the skin)
Decreased urine output
Fatigue and weakness
Management:
Administer supplemental oxygen to improve oxygenation and relieve respiratory distress
Administer diuretics to reduce fluid accumulation and improve cardiac output
Administer nitroglycerin to dilate blood vessels and reduce preload
Administer morphine for pain relief and to reduce anxiety
Elevate the head of the bed to reduce venous return to the heart
Monitor vital signs, including oxygen saturation, blood pressure, heart rate, and urine output
Perform chest x-ray and electrocardiogram (ECG) to assess the severity of pulmonary edema
and identify underlying cardiac abnormalities
Consider referral to a specialist for further management and treatment, such as mechanical
ventilation, inotropic agents, or surgical intervention.

Mention the principles of management of acute left ventricular failure?
(DU- 18Nov) Write down the management
The principles of management of acute left ventricular failure include:
Oxygen therapy: Supplemental oxygen is given to improve oxygen saturation and alleviate
dyspnea.
Diuretics: Loop diuretics like furosemide are given to reduce volume overload and alleviate
pulmonary congestion. Diuretics can cause electrolyte imbalances, so they must be used
judiciously.
Vasodilators: Nitroglycerin and other vasodilators like nitroprusside are used to reduce
preload and afterload, thus decreasing the workload on the heart.
Inotropic agents: These are medications that increase the contractility of the heart. They are
used in severe cases of acute left ventricular failure when other measures have failed.
Management of underlying conditions: Acute left ventricular failure may be due to a
number of underlying conditions like myocardial infarction, hypertension, or valvular heart
disease. Treating the underlying condition is important in managing acute left ventricular
failure.
The specific management of acute left ventricular failure depends on the severity of the
condition and the underlying cause. It is important to closely monitor the patient's response to
treatment and adjust therapy accordingly. In severe cases, hospitalization may be necessary for
more aggressive management.
A 60 year old man presents in the emergency department with severe
retrosternal chest pain for 2 hours sweating. His pulse rate 110/min
with regular rhythm, blood pressure 160/110 mmHg, and apex beat
heving. (DU- 22M)
a. Write down investigations for him along with expected findings.
b. How would you treat him?
a. The following investigations can be performed for the patient along with their expected
findings:

Electrocardiogram (ECG): ST segment elevation indicating acute myocardial infarction
(heart attack).
Cardiac enzymes (troponin, creatine kinase-MB): elevated levels indicating myocardial
damage.
Chest X-ray: may show signs of cardiomegaly (enlarged heart) or pulmonary congestion.
Echocardiogram: may reveal decreased left ventricular function and/or wall motion
abnormalities.
b. The patient is likely experiencing an acute myocardial infarction and should be treated as
an emergency. The following management steps can be taken:
Administer aspirin and nitroglycerin sublingually.
Provide oxygen therapy.
Start intravenous access and administer pain relief with morphine.
Consider antiplatelet therapy with clopidogrel or ticagrelor.
Transfer the patient to a cardiac care unit for further management, which may include
percutaneous coronary intervention (PCI) or thrombolysis.
b. How would you treat him?
The initial treatment for the patient with suspected acute coronary syndrome includes:
Administering aspirin: The patient should receive 300 mg of aspirin as soon as possible, as it
helps to prevent the formation of blood clots in the coronary arteries.
Nitroglycerin: Nitroglycerin can be given sublingually to relieve chest pain by relaxing the
smooth muscles in the blood vessels and increasing the blood supply to the heart.
Oxygen therapy: Oxygen is given to maintain oxygen saturation above 90% and improve
oxygen supply to the heart.
Morphine: If the patient's chest pain is not relieved with nitroglycerin, morphine can be given
to reduce pain and anxiety.
Beta-blockers: Beta-blockers are given to reduce the heart rate and blood pressure and to
protect the heart muscle from damage.

Reperfusion therapy: If the patient has ST-elevation myocardial infarction (STEMI),
reperfusion therapy such as thrombolytic therapy or primary percutaneous coronary
intervention (PCI) should be done to restore blood flow to the affected coronary artery.
Other medications: Other medications such as heparin, clopidogrel, and statins may be given
depending on the individual case.
It is important to monitor the patient's blood pressure, heart rate, and oxygen saturation continuously.
Once the patient is stabilized, further investigations such as ECG, cardiac enzymes, and
echocardiogram should be done to confirm the diagnosis and determine the extent of myocardial
damage.
5. A 55 year old man presents in the emergency department with severe
breathlessness. Clinical examination reveals his blood pressure
220/120 mmHg, pulse rate 120/min with regular rhythm, apex beat
heaving and bilateral basal crepitations on auscultation of lung.
(DU- 20Nov)
a. Write down investigations for him along with expected findings.
b. How will you treat him?
a. Investigations that can be done for this patient with expected findings include:
Electrocardiogram (ECG): may show evidence of left ventricular hypertrophy, atrial
fibrillation or other arrhythmias, ischemia, or infarction.
Chest X-ray: may reveal pulmonary edema with bilateral infiltrates.
Echocardiogram: may demonstrate left ventricular hypertrophy, decreased left ventricular
ejection fraction, or valvular abnormalities.
Complete blood count (CBC): may show elevated hematocrit or hemoglobin level due to
hemoconcentration.
Renal function tests: may reveal elevated creatinine and blood urea nitrogen (BUN) levels.
Serum electrolyte levels: may show electrolyte imbalances, especially hyperkalemia.
b. The treatment of this patient will depend on the underlying cause of his symptoms, but may
include:
Oxygen therapy: to improve oxygenation and alleviate breathlessness.
Diuretics: such as furosemide, to reduce fluid overload and relieve pulmonary edema.
Antihypertensive medications: such as intravenous nitroglycerin, hydralazine or labetalol to
lower blood pressure.

Morphine: may be used to relieve pain and anxiety, and to reduce preload on the heart.
Management of underlying conditions: such as heart failure, arrhythmias, or acute coronary
syndrome.
Close monitoring: including continuous electrocardiogram and blood pressure monitoring, as
well as regular assessments of oxygen saturation and respiratory function.
b. How will you treat him?
The management of this patient with severe breathlessness and hypertensive emergency would
involve the following steps:
Immediate treatment: The patient should be given oxygen to improve oxygenation and
reduce the workload on the heart. Intravenous medications to reduce blood pressure should
also be given immediately.
Control of blood pressure: The goal of treatment is to reduce the blood pressure gradually,
as a sudden drop in blood pressure can cause organ damage. Intravenous medications like
nitroglycerin, labetalol, nicardipine, or sodium nitroprusside can be used to lower blood
pressure. Blood pressure should be monitored frequently, and the medications should be
adjusted accordingly.
Treatment of heart failure: The patient's symptoms of heart failure should be managed by
giving medications like diuretics to reduce fluid overload in the lungs. In severe cases,
intravenous inotropes like dobutamine can be given to improve the heart's function.
Investigations: Investigations should be done to identify the underlying cause of hypertensive
emergency, which may include blood tests, electrocardiogram (ECG), echocardiogram, chest
X-ray, and CT scan.
Follow-up: The patient should be closely monitored in the hospital for several hours until
blood pressure is stabilized. The patient should be advised to follow up with their primary care
physician for further management of hypertension and heart failure.
In summary, the treatment of hypertensive emergency involves immediate control of blood
pressure, management of heart failure symptoms, investigations to identify the underlying
cause, and close monitoring in the hospital.

6. A 50 years old male presents with sudden severe breathlessness for 4 hours.
Examination reveals pulse- 108/min, BP/100 mm of Hg and having bilateral
basal crackles. (DU-18Ja)
a. What clinical information would you search for its etiology?
b. How would you manage this case ?
a. In order to determine the etiology of sudden severe breathlessness, clinical information that should
be searched for includes:
 Any history of underlying lung or heart disease
 Any recent trauma or surgery
 Any history of exposure to toxins or chemicals
 Any recent travel or history of deep vein thrombosis (DVT)
 Any signs or symptoms of infection
 Any medication history, particularly recent changes or additions
 Any history of allergies or asthma
b. The management of this case would depend on the underlying cause of the sudden severe
breathlessness. Some general steps that can be taken to manage the patient include:
 Administering oxygen to maintain adequate oxygen saturation levels
 Administering bronchodilators or other medications to alleviate respiratory distress
 Administering diuretics if there is evidence of fluid overload
 Administering antibiotics if there is evidence of infection
 Administering anticoagulants if there is evidence of pulmonary embolism or DVT
 Admitting the patient to the hospital for further evaluation and management
 Providing supportive care, such as ensuring adequate hydration and nutrition.
differential diagnosis
Based on the given information, the differential diagnosis for the patient's sudden severe breathlessness
with bilateral basal crackles includes:
 Pulmonary embolism
 Acute exacerbation of chronic obstructive pulmonary disease (COPD)
 Acute left ventricular failure
 Acute respiratory distress syndrome (ARDS)
 Pneumonia
 Asthma exacerbation
 Interstitial lung disease

 Cardiac tamponade
 Anaphylaxis
 Panic attack
It is important to obtain further information about the patient's medical history, risk factors, and clinical
examination findings to arrive at a more accurate diagnosis and appropriate management plan.
b. How would you manage this case ?
The management of this case would depend on the underlying cause of the sudden severe
breathlessness. However, some initial management steps that can be taken include:
 Administering oxygen: The patient may be given supplemental oxygen to help improve their
breathing and oxygen saturation levels.
 Diuretics: If the patient has heart failure, diuretics may be given to help reduce fluid overload in
the lungs.
 Bronchodilators: If the patient has an underlying lung disease, such as asthma or chronic
obstructive pulmonary disease (COPD), bronchodilators may be given to help open up the
airways and improve breathing.
 Treating the underlying cause: Once the underlying cause of the breathlessness has been
identified, specific treatment can be given. For example, if the patient has a pulmonary embolism,
they may require anticoagulation therapy or thrombolytics.
 Close monitoring: The patient should be closely monitored for any changes in their condition,
including vital signs, oxygen saturation levels, and symptom improvement or worsening.
In some cases, the patient may need to be admitted to the hospital for further management and
monitoring.
7. A 50 year old male presents with orthopnoea. Examination reveals BP-
190/120 mmHg. Bilateral basal crepitation are present. (DU-15Ja)
a. What is the most likely diagnosis? How will you investigate him?
b. How will you manage this case?
a. The most likely diagnosis for this case is pulmonary edema secondary to left ventricular
failure. Investigations that can be done to confirm the diagnosis and determine the severity of
the condition include:
 Chest X-ray: to look for signs of fluid accumulation in the lungs

 ECG: to assess the heart rhythm and look for any evidence of myocardial infarction or
other cardiac abnormalities
 Echocardiography: to evaluate the function of the heart and identify any structural
abnormalities or valve defects
 Blood tests: to check for markers of heart failure and assess kidney and liver function.
b. The management of this case will depend on the severity of the pulmonary edema and the
underlying cause. The following measures can be taken:
 Oxygen therapy to improve oxygenation
 Intravenous diuretics such as furosemide to reduce fluid overload
 Nitroglycerin to reduce preload and afterload
 ACE inhibitors or angiotensin receptor blockers to improve cardiac function
 Morphine sulfate to reduce anxiety, pain, and preload
 Continuous positive airway pressure (CPAP) or mechanical ventilation in severe cases.
Additionally, the underlying cause of left ventricular failure should be identified and treated
accordingly. This may involve the management of hypertension, coronary artery disease, or
valvular heart disease.
b. How will you manage this case?
The management of a patient with the diagnosis of acute pulmonary edema typically involves the
following steps:
 Oxygen therapy: The patient should be given oxygen therapy to improve oxygenation and
relieve respiratory distress. Oxygen can be given through a nasal cannula or a face mask.
 Diuretics: Intravenous (IV) loop diuretics like furosemide should be given to reduce preload and
decrease fluid accumulation in the lungs. The dosage should be titrated based on the patient's
response.
 Vasodilators: IV vasodilators like nitroglycerin or nesiritide can be given to reduce afterload and
improve cardiac output. The dosage should be titrated based on the patient's blood pressure and
symptoms.
 Morphine: IV morphine can be given to relieve anxiety and reduce preload by venodilation.
 Blood pressure management: The patient's blood pressure should be carefully monitored
and managed. If the patient has hypertensive crisis, intravenous antihypertensive agents like
nitroprusside or labetalol can be used.

 Monitoring: Continuous monitoring of vital signs, urine output, and oxygen saturation should be
performed to assess the patient's response to treatment.
 Treat the underlying cause: The underlying cause of acute pulmonary edema should be
identified and treated accordingly. For example, if the patient has myocardial infarction, prompt
reperfusion therapy should be given.
In severe cases, the patient may require mechanical ventilation, continuous positive airway pressure
(CPAP), or intubation and mechanical ventilation. Once the patient's condition is stabilized, the patient
should be carefully monitored and managed to prevent recurrence of acute pulmonary edema.
A 55 years old man is admitted with long history of uncontrolled hypertension
with breathlessness for 3 days. (DU- 13Ja)
a. What are the expected clinical findings?
b. Mention the necessary investigation for the patient.
a. The expected clinical findings in a patient with long-standing uncontrolled hypertension
and breathlessness for 3 days may include elevated blood pressure, tachycardia, difficulty in
breathing, crackles on lung examination, and signs of fluid overload such as pedal edema.
b. Necessary investigations for this patient may include:
 Blood tests: To assess kidney function, electrolyte levels, and liver function.
 Chest X-ray: To evaluate the condition of the lungs and heart.
 Electrocardiogram (ECG): To check for any abnormalities in heart rhythm or electrical
activity.
 Echocardiogram: To assess the structure and function of the heart, including the size of
the heart chambers and the strength of the heart muscle.

 Brain natriuretic peptide (BNP) test: To measure the levels of a hormone that is
released in response to heart failure.
 Urine tests: To check for proteinuria, which is an indication of kidney damage.
 Arterial blood gas analysis: To assess the levels of oxygen and carbon dioxide in the
blood.
 Holter monitoring: To record the heart's electrical activity over a 24-hour period.
 Pulmonary function tests: To evaluate lung function.
These investigations will help in diagnosing the underlying cause of the patient's symptoms
and determining the appropriate treatment plan.
a. What are the expected clinical findings?
b. The expected clinical findings in a 55-year-old man with a long history of uncontrolled
hypertension and breathlessness for 3 days can include:
Elevated blood pressure: The patient's blood pressure is likely to be high due to his uncontrolled
hypertension.
Breathlessness: The patient may experience shortness of breath, especially on exertion or when lying
down.
Fatigue and weakness: The patient may feel tired and weak due to poor oxygenation of tissues.
Swelling: The patient may have swelling in the legs, ankles, or feet due to fluid buildup.
Abnormal heart sounds: The patient may have abnormal heart sounds such as a gallop rhythm,
indicating heart failure.
Chest discomfort: The patient may have chest discomfort or pressure due to an underlying cardiac
condition.

The causes of these clinical findings may include uncontrolled hypertension leading to left ventricular
hypertrophy, diastolic dysfunction, and heart failure. The patient may also have underlying coronary
artery disease or valvular heart disease contributing to his symptoms.
A patient presented with generalized edema, tender hepatomegaly and elevated
JVP. (DU-12Ja)
a. What is your probable diagnosis?
b. Make a list of investigation with expected findings you expect to come across with.
c. How will you manage the case?
a. The probable diagnosis in this case is right-sided heart failure.
b. List of investigations and expected findings:
 Echocardiogram: It can help identify any underlying structural or functional abnormalities in the
heart, such as reduced ejection fraction, valvular disease, or pericardial effusion.
 Chest X-ray: It may show an enlarged cardiac silhouette, pulmonary congestion, or pleural
effusion.
 Electrocardiogram (ECG): It can help identify any underlying arrhythmias or ischemia.
 Blood tests: These may include a complete blood count, electrolyte panel, renal function tests,
liver function tests, brain natriuretic peptide (BNP) levels, and cardiac troponin levels.
 Urinalysis: It may show proteinuria or hematuria.
c. Management of right-sided heart failure involves treating the underlying cause and managing
symptoms. In this case, the following management strategies may be considered:
 Diuretics: They help reduce fluid overload and improve symptoms of congestion.
 ACE inhibitors or angiotensin receptor blockers (ARBs): They can help improve cardiac
function and reduce symptoms.
 Beta-blockers: They can help improve cardiac function and reduce the risk of arrhythmias.
 Sodium restriction: It can help reduce fluid retention.

 Management of underlying conditions: Treatment of underlying conditions such as
hypertension or valvular disease is essential in managing right-sided heart failure.
In severe cases, hospitalization may be required for intensive management with intravenous diuretics
and monitoring of electrolyte imbalances and other complications.
2. Name the drugs used in heart failure with their advantages and limitations. (DU- 11Ju)
There are several drugs used in heart failure with their own advantages and limitations. Some of the
commonly used drugs are:
 Diuretics - such as furosemide, which help to reduce fluid overload in the body by increasing
urine output. The advantage is that they can rapidly improve symptoms of congestion, but the
limitation is that they can cause electrolyte imbalances and dehydration.
 Angiotensin-converting enzyme (ACE) inhibitors - such as lisinopril, which help to relax blood
vessels and decrease the workload on the heart. The advantage is that they can improve symptoms,
slow the progression of heart failure, and reduce the risk of hospitalization, but the limitation is
that they can cause a persistent cough.
 Angiotensin receptor blockers (ARBs) - such as losartan, which also help to relax blood vessels
and decrease the workload on the heart. The advantage is that they can improve symptoms and
slow the progression of heart failure, but the limitation is that they can cause dizziness and
hypotension.
 Beta blockers - such as carvedilol, which help to decrease the heart rate and improve heart
function. The advantage is that they can improve symptoms, reduce the risk of hospitalization,
and improve survival, but the limitation is that they can cause fatigue and worsen symptoms in
some patients.
 Mineralocorticoid receptor antagonists (MRAs) - such as spironolactone, which help to reduce
fluid overload and improve heart function. The advantage is that they can improve symptoms and
reduce the risk of hospitalization and mortality, but the limitation is that they can cause
hyperkalemia.
 Ivabradine - which slows the heart rate without affecting blood pressure or contractility. The
advantage is that it can improve symptoms and reduce the risk of hospitalization, but the
limitation is that it can cause bradycardia.
The choice of drug depends on the severity of heart failure, comorbidities, and other individual factors.

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