Case History 12: Congestive Heart Failure

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Chief Complaint:68-year-old man who collapsed during exertion.

History:Roger Crockett, a 68-year-old man with a 40-pack-year smoking history and recent complaints of angina (sub-sternal chest pressure) upon exercising, collapsed while mowing his lawn. Paramedics arriving at the scene found him unconscious, not breathing, and without a pulse. CPR was successfully performed and Roger was transported to the hospital. An ECG was suggestive of an anterior wall myocardial infarction, and he was given an intravenous solution of tissue plasminogen activator (TPA). Elevated blood creatine phosphokinase (CPK) levels measured over the next 2 days confirmed the diagnosis. Coronary angiography was performed a week later, revealing the following results:

Circumflex artery: 20% blocked
Right coronary artery: 15% blocked
Left anterior descending artery (LAD): 95% blocked
("Anterior intraventricular artery")  

Questions:

1. While listening to his heart with a stethoscope, you notice a high-pitched, blowing, systolic murmur, heard best directly under the left nipple. A review of Roger's medical records shows no prior history of a heart murmur. What is causing this new murmur?

Answer

2. Is the cause of the murmur in any way related to his heart attack? Explain.

Answer

3. While listening to his breathing with a stethoscope, you hear some wheezing and inspiratory rales ("crackling noises"). Explain these findings.

Answer

4. A chest X-ray taken two weeks after his collapse shows a markedly enlarged cardiac silhouette and generalized haziness at the bases of the lungs.

A. Why is the heart enlarged?

Answer

B. Why are the lungs "hazy" on chest X-ray?

Answer

5. Roger is stabilized and ultimately discharged from the hospital. Three months after the heart attack, he comes back to his physician for a checkup. He complains of dyspnea ("shortness of breath") at rest and difficulty breathing while lying down ("orthopnea"). He says he can only sleep when he is propped up by two large pillows. Why is he having these symptoms?

Answer


6. What is the general name for Roger's condition?

Answer

7. Which term more accurately describes the stress placed upon Roger's heart -- increased pre-load or increased aferload?

Increased pre-load or Increased afterload?

Answer


8. Why does it help Roger to sleep with pillows under his head?

Answer

9. What is creatine phosphokinase (CPK) and why are elevated CPK levels in the blood suggestive of a myocardial infarction (heart attack)?

Answer

10. What is tissue plasminogen activator (TPA), what is it used for, and how does it work?

Answer

 

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