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Course 5
Case 19
Kas 5-19E: Heart failure and shock.
Pavel Stanka, MD.
Patient: male, 53 years.
History of presenting complaint. A 53 years old, so far healthy, warehouseman comes to
emergency for progressive dyspnoea. For the last 3 weeks, he is observing dyspnoea on
minimal effort and sometimes also at rest and at nights. Furthermore, he is complaining of an
intermittent dull pressure behind the lower sternum without radiation. No complaints of
palpitation, sporadically nausea. Since introduction of therapy by general practitioner, he has
experienced some improvement of symptoms.
Past history: never seriously ill
Approximately 10 years ago, in-hospital observation for dyspepsia (nausea)
Social habits: Former smoker, twenty cigarettes a day since his 17, nonsmoker for the last 6
years, alcohol- 5 pints of beer and two shots of liqueur a day
Medication: furosemide 40mg 1-0-0 tbl, spironolacton 25mg 1-1-1 tbl, B-vitamins
Family history: father unknown, mother died at 69 of stroke, brother died at 68 of lung
disease. He does not know any details.
Physical examination: 72 kg, 165 cm, no resting dyspnoea, no cyanosis, whole body tremor,
head: chronic stomatitis, pharyngitis, jugular vein distension reaching up to one half of the
neck, breathing with medium inspiratory crackles over both lung bases. HR 140/min, gallop,
soft abdomen, liver 1 cm bellow right costal margin, no peripheral edemas, BP 120/80mmHg
ECG: at admission, sin rhythm, 136/min, horizontal axis, PQ 0,16, flat negat. T aVL, T+V4,V5
After treatment, sinus 84/min, flat negat. T aVL, T+-V3-V5
Course 5
Case 19
Course 5
Case 19
Chest X-ray: lungs without infiltration, heart is dilated to the left
Course 5
Case 19
Echocardiography (normal values in parentheses: left ventricle 73mm (within 60mm), EF
30% (over 55%), septum thickness 11mm (within 12mm), posterior wall 10-11mm (within
12mm), left atrium 44mm (within 43mm), right ventricle 26mm (within 30mm), diffuse
hypokinesis of the left ventricle, pericardium without effusion
Spirometry: Normal
Coronary and left ventricular angiography: Intermediate LAD stenosis (60%), diffuse
hypokinesis EF 30%, performed ad hoc PCI with stent implantation in LAD
Sonography of abdomen: Diffuse liver lesion of steatosis type, right liver lobe is of uppernormal size.
Blood tests: elevated liver enzymes (ALT 2,3 ukat/l, AST 1,47 ukat/L), slightly elevated
plasma ammonia
Questions
1. Make a list of admission diagnoses arranged in order by priority.
2. What is a likely cause of patient disease?
3. What therapeutic measures would you suggest to treat the acute phase and to prevent the
progression of the disease?
4. What causes of heart failure do you know?
5. Types of cardiomyopathy
6. Etiology of tremor