1.1 mdm chuan - nigel fong

Mdm Chuan

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Mdm Chuan isa67-year-oldlady,ADL-independent,community-ambulant.Herpremorbids includediabetes,ischaemicheartdisease,atrialfibrillationonwarfarin,anda40pack-yearhistoryofsmoking.Shepresentswitha3-weekhistoryofprogressiveshortnessofbreaththatisworseonlyingdown.Sheusedtojog2-3km,butnowgetsverybreathlessonwalking1busstop’sdistance.Thereisnochestpain,palpitations,diaphoresis,cough,orfever.Onexamination,hervitalsareBP165/84,HR80,RR24,SpO293%on2LO2,Tempafebrile.Sheisinslightrespiratorydistress.Conjunctivaearepale.Firstandsecondheartsoundsareheardwithnomurmurs.Thereisnoparasternalheave.Scatteredcrepitationsandexpiratoryronchiareheardinbilaterallowerlungfields.Thejugularvenouspressureiselevatedwithbilateralpittingedema.Digitalrectalexaminationrevealsbrownstools.

Q1.Whichofthefollowingbestdifferentiatecardiacfromrespiratorycausesofdyspnoea?(Choose2of7)• Previoussmokinghistory• Orthopnea• Reducedefforttolerance

• Hypoxaemia• Respiratorydistress• Expiratoryronchi• Elevatedjugularvenouspressure

CLINICAL REASONING

• Each step of the reasoning process: Hx > PE > Inx helps to refine your ddx

• Ask the right questions and you will get the right answers

• Keep asking ‘why’

• Sometimes you might need to proceed based on two possible pathologies

USING SCHEMATA

Schemata implies some qns to ask:• Descriptor qns: To characterize symptoms and identify

the correct schemata to use (very important!)• Differentiator qns: Key branch points to discriminate btw

different categories of diagnoses• Confirmatory qns: Evidence in favour of specific end

diagnoses in the schemata (specific)• Red flags: To rule out dangerous diagnoses (sensitive)

Schemata implies what physical exam to do:• Targeted exam: you won’t find what you don’t look for; you

won’t look for what you don’t think of.

USING SCHEMATA

How to learn schemata:• See: Clinical experience provides a bank of illness scripts

to draw on. Seeing different diseases with the same presentation & the same disease with different presentations helps to identify key discriminators.

• Think: Mental processing of clinical experiences (full understanding, making links, compare & contrast) is essential. Rubbish in, rubbish out

• Read: Build on existing & classical schemata; use them to help you organize your knowledge structure.

• Build: Try to construct your personal schemata

• Refine: Use your schemata & think how to improve it

USING SCHEMATA

Pitfalls:• Using wrong schemata: a fatal mistake. Arises when

descriptive qns on presenting complaint are glossed over.• Over-reliance on branch points: Often dangerous to

rule out entire categories based on a single differentiator qn. Often have to pursue multiple categories in parallel.

• Overly narrow differential: consider & prioritize the most likely ddx; always consciously rule out the most dangerous ddx – be safe.

• Atypical presentations: May not be captured in schemata (unless common enough, or schemata comprehensive enough).

BasiclaboratorystudiesperformedbytheA&Ereveal:Hb 7.2(MCV78) Na143 Iron3.7(11-27)TW9.6 K4.5 Transferrin4.2(1.8-3.8)Plt 237 Cl100 Ironsaturation4%

HCO322 Ferritin9.2(7.6-179)Troponinnormal Cr57 B12/folatenormal

Anelectrocardiogramshowsanoldrightbundlebranchblock.TheCXRisshownbelow.Herlastechocardiogramin2010wasnormalwithEF60%.

Q2.Astheon-callHO,whichofthefollowingtherapieswouldyouinitiate?(Choose3of10)• Cessationofwarfarintherapy• IVFurosemide40mgstat+OM• Nebulizedsalbutamol• POAspirin100mg• POMorphine5mgPRN• POVitaminK2mg• Non-invasiveventilation• Referraltocardiologyon-call• Transfusionof1pintPCT• Transfusionof1pintFFP

SYSTEMATIC APPROACH TO CXR

• A irway

• B ones• C ardiac

• D iaphragm

• E ffusion• F ields (lung)

• G astric bubble• H ilum /mediastinum

APPROACH TO ANAEMIA

Iron studies• Iron 3.7 (11-27)• Transferrin 4.2 (1.8-3.8)• Iron saturation 4% --- <16% suggests iron deficiency• Ferritin 9.2 (7.6-179) --- May be high in acute inflammatory state• B12/folate normal

LOOK AT THE WHOLE FBCContext Hb RBC WBC Plt MCV Hct ReticA. Blood loss 13 4.5 7 250 85 40 1B. Blood loss 10 3 5 150 85 28 1C. Blood loss 12 4 7 250 85 35 4D. Asymptomatic 8 3 7 250 73 38 2E. Asymptomatic 8 5.3 7 250 61 38 2F. Asymptomatic 8 3 7 250 105 38 2G. ESRF, dialysis 7 3 7 250 85 36 0.4H. 1-yr symptoms 5 2 0.5 65 85 30 0.2I. Dark urine 1/52 10 3 7 250 85 35 4J. Fever x 1/52 12 5 7 50 85 35 2K. 1-yr purpura 12 5 7 50 85 35 2L. Malaise x 3/12 11 3 50 70 85 35 1

INDICATION FOR TRANSFUSION

Somewhat variable between managing physicians.

RBCs• Hb < 7 for non-IHD• Hb 9-10 for active IHD. • Massive blood loss – don’t just transfuse RBCs!

Platelets• Plt <10, asymptomatic• Plt <20, septic (?)• Plt <50, bleeding or major surgery• Plt <100, critical site bleeding or critical site surgery

APPROACH

• Have to keep track of information presented so far and visualize the patient in front of you

• Be used to interpreting data and refining your dx.• By this point (in exam / in real world) you must have

generated a problem list.

BasiclaboratorystudiesperformedbytheA&Ereveal:Hb 7.2(MCV78) Na143 Iron3.7(11-27)TW9.6 K4.5 Transferrin4.2(1.8-3.8)Plt 237 Cl100 Ironsaturation4%

HCO322 Ferritin9.2(7.6-179)Troponinnormal Cr57 B12/folatenormal

Anelectrocardiogramshowsanoldrightbundlebranchblock.TheCXRisshownbelow.Herlastechocardiogramin2010wasnormalwithEF60%.

APPROACH

• By this point (in exam / in real world) you must have generated a problem list.1. Fluid overload 2’ CCF2. CCF ppt by anaemia, ? underlying cardiac dx3. Iron deficiency anaemia for workup.

• For each problem, think about• How to confirm dx?• How to identify cause?• How to look for complications?• How to treat?

Bynextmorning,Mdm Chuan issymptomaticallymuchbetter,nolongerrequiringoxygen.Serialtroponinsarenormal.Theteam’sworkingdiagnosisisfluidoverload.

Q3.AllofthefollowinginvestigationsshouldbeorderedEXCEPT(Choose1)• Colonoscopy• Echocardiography• Oesophagoduodenoscopy• Stresselectrocardiogram• Thyroidfunctiontests

CLINICAL QUESTIONS IN CCF

1. Is the diagnosis CCF?• “a complex clinical syndrome that can result from any

structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood”

• Presentation differs based on time course> Acute > Subacute > Chronic

• Ddx: CKD, COPD, hypoalbuminaemia• Symptoms + Signs + Inx ( ? scoring systems)• Role of pro-BNP• Role of 2DE


1. Is the diagnosis CCF?2. Is this HF-pEF or HF-rEF (preserved vs reduced EF)?


1. Is the diagnosis CCF?2. Is this HF-pEF or HF-rEF (preserved vs reduced EF)?3. What is the severity?

Chronic: NYHA


1. Is the diagnosis CCF?2. Is this HF-pEF or HF-rEF?3. What is the severity?

Chronic: NYHAAcute:

Euvolemic Fluid O/L

Good cardiac output

Warm & Dry Warm & Wet

Poor cardiac output

Cold & Dry Cold & Wet



Chronic: NYHAAcute: warm/cold vs wet/dry

4. What is the etiology?• Plumbing: IHD • Pump: valvular disease, cardiomyopathies• Electricity: arrhythmias• Circuit: HTN, thyroid, etc• What to look for in the echo?



Chronic: NYHAAcute: warm/cold vs wet/dry

4. What is the etiology?5. What are the complications?

EchocardiographyrevealsEF43%withregionalwallmotionabnormalities;allvalvesarenormal.HbA1cis6.4%.Thyroidfunctiontestsarenormal.InpatientsystolicBPtrendis140-160mmHg.Outpatientcolonoscopyisscheduled.Hercurrentmedicationsare:POBisoprolol2.5mgBDPOFerrousFumarate 200mgBDPOFurosemide20mgOMPOMetformin500mgBDPOSimvastatin20mgONPOWarfarin2mgON(suspended)SublingualGTN0.6mgPRN

Q4.Whatadjustmentwouldyoumaketohermedications?(Choose1)• AddPOaspirin100mgOM• AddPOenalapril 5mgBD• AddPOdigoxin62.5mcgOM• AddPOglipizide2.5mgBD• AddPOnifedipine LA30mgOM

Q5.Mdm Chuan isputonenalapril andatorvastatin.Inadditiontopharma-cological therapy,youwouldadviceallofthefollowingEXCEPT(Choose1)• Counselforautomatedimplantablecardioverter-defibrillator(AICD)placement.• Enrollmentinanexerciseprogramme• Influenzavaccination• Recheckrenalpanelin1week• Smokingcessation

MANAGEMENT OF CCF

1. Treat the etiology• Aggressive vascular risk factor modification

- Pharmacological- Nonpharmacological – stop smoking

• Revascularization if indicated• Secondary prevention - aspirin

MANAGEMENT OF CCF

1. Treat the etiology2. Relieve symptoms and maximise function

• Pharmacological - Diuresis - Role of digoxin (?)

• Nonpharmacological- Diet, exercise, fluid restriction- Cardiac rehab

MANAGEMENT OF CCF

1. Treat the etiology2. Relieve symptoms and maximise function3. Inhibit cardiac remodelling and reduce risk

• ACE/ARB• Evidence-based beta blocker (Biso, carve, meto)• Spironolactone (NYHA 2 EF ≤30%, NYHA 3-4 EF

<35%, or previous STEMI EF ≤40%)• Device therapy

- Cardiac resynchronization therapy- Implantable cardioverter-defibrillator

MANAGEMENT OF CCF

1. Treat the etiology2. Relieve symptoms and maximise function3. Inhibit cardiac remodelling and reduce risk4. Prevent exacerbations

• Vaccinations• Compliance• Precipitating drugs

MANAGEMENT OF CCF

1. Treat the etiology2. Relieve symptoms and maximise function3. Inhibit cardiac remodelling and reduce risk4. Prevent exacerbations5. Treat comorbids

• Side effects• Disease-disease, drug-drug, drug-disease interactions

MANAGEMENT OF CCF

1. Treat the etiology2. Relieve symptoms and maximise function3. Inhibit cardiac remodelling and reduce risk4. Prevent exacerbations5. Treat comorbids6. Consider: how is this affecting the patient?

Remember: it’s not just about drugs.Holistic, multidisciplinary care is not just a slogan.

Mdm Chuan isdischargedwithanappointmentforoutpatientcolonoscopy.

Q6.WhichofthefollowingstatementsareFALSE?(Choose1)• Bisoprolol shouldbecontinuedonthedayofendoscopy• Endoscopyshouldbepostponedifsheisstillinfluidoverload.• Congestivecardiacfailureisacontraindicationtobowelprepwith2Lpolyethyleneglycol(PEG).

• Sheshouldbecounselledonanelevatedriskofmajoradversecardiacevent(MACE)withsedation.

Mdm Chuan isdischargedwithanappointmentforoutpatientendoscopy.

Q6.WhichofthefollowingstatementsareFALSE?(Choose1)• Bisoprolol shouldbecontinuedonthedayofendoscopy• Endoscopyshouldbepostponedifsheisstillinfluidoverload.• Congestivecardiacfailureisacontraindicationtobowelprepwith2Lpolyethyleneglycol(PEG).

• Sheshouldbecounselledonanelevatedriskofmajoradversecardiacevent(MACE)withsedation.

Mdm Chuan undergoescolonoscopyuneventfully,whichfindsnoabnormalityapartfromdiverticulardisease.Sheisdischargedonoptimummedicaltherapy.Twomonthslater,sheisreadmittedcomplainingofatwo-dayhistoryofworseningshortnessofbreath.HervitalsareT37.9,BP185/107,HR107,SpO292%onroomair.Examinationisnormalapartfrombibasal lungcrepitationsandbilateralpittingpedaledema.ChestX-rayisconsistentwithpulmonarycongestion.

Q7.WhichofthefollowinginitialstepsistheLEASTappropriate?(Choose1)• Explorecompliancetomedicationandfluidrestriction• Repeatechocardiogram• Repeatfullbloodcount• Septicworkup• SerialECGsandcardiacenzymes

Furtherquestioningrevealsa4-dayhistoryofupperrespiratorytractsymptoms,malaise,andfever.Inaddition,shehadnotbeencomplianttofluidrestrictioninthepast4daysbecauseshefeltthattakinglargeamountsofwaterwouldhelpherrecovermorequickly.Fullbloodcountandserialcardiacenzymesarenormal.

Q8.WhichofthefollowingmanagementoptionsaretheLEASTappropriate?(Choose2)• Dailymonitoringofrenalfunctionandelectrolytes• Influenzavaccinationondischarge.• IVdopamine• IVdigoxin• IVfurosemide• IVGTN• Strictintake/outputchartinganddailyweights

EXACERBATIONS OF CCF

1. A-B-C: ensure adequate BP, no respi failure2. Confirm CCF (consider ddx)3. Identify and treat precipitant

• Plumbing: ACS• Pump: valve, other structural lesions• Electricity: arrhythmias• Circuit: HTN emergency• Non-cardiac: infection, PE, COPD etc.


1. A-B-C: ensure adequate BP, no respi failure2. Confirm CCF (consider ddx)3. Identify and treat precipitant4. Treat clinical picture

Euvolemic Fluid overloaded

Good cardiac output

Warm and Dry- Cont. mx

Warm and Wet- Diuresis- Vasodilators

Poor cardiac output

Cold and Dry- Judicious fluids- KIV inotropes

Cold and Wet- Inotropes- Diuretics- Vasodilators- Device (IABP, VAD etc)


1. A-B-C: ensure adequate BP, no respi failure2. Confirm CCF (consider ddx)3. Identify and treat precipitant4. Treat clinical picture5. Optimise chronic mx and mitigate further precipitants

LEARNING OUTCOMES

Skills1. Clinical reasoning: using schemata and iterative

reasoning to arrive at ddx2. Synthesis of information & generating a problem list

3. The clinical questions approach

Content:1. Congestive cardiac failure2. Approach to anaemia

1.1 mdm chuan - nigel fong

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