Clinical case

• Patient ,male, 69 years old, a retired

teacher, was admitted on June 6, 2016,
because of shortness of breath and
recurrant edema in recent past 6
months.
• In the recent past 6 months, the patient felt
shortness of breath during hard work, fast
walk, or climbing stairs. There was recurrent
swelling of legs, especially after activity.
Occasionally, he displayed paroxysmal
nocturnal dyspnea and had nonproductive
cough.
• However, in recent 1 month, edema and
dyspnea become so serious that he could
neither walk and lie down. He had to sit up
during the whole night. Sometimes he
coughed with lots of sputum, but without
blood. He had no fever, chill, chest pain.
• In recent 2 days, the urine volume reduced
and abdomen circumference increased. He
had a poor appetite and felt nausea usually.

• There was nothing else abnormal in the

review history. He had no history of drug
allergy.
 Question 1
• What do you thinck about the diagnosis
for the patient initially?
 Question 2
• According to the New York Heart Association classification
of cardiac function, what do you think about the patient?
• Why
 Question 3
• Are there any primary cardiac disease and
precipitating factors?
 Question 4
• Next step, about the physical examination,
what will you focus on?
 Physical Examination

 T.36.8℃, P. 96/min, R. 28/min,

Bp 102/76mmHg. He was mentally normal

and cooperative in the examination.he
was lying in bed with a semi-lying position.
 Physical Examination

The chest and respiratory movements

were rapid. Some moist rales were heard
in the whole areas of bilateral lungs.
 Physical Examination

The heart rate was 120/min, regular,. The

point of apex impulse was visible in the 5th
costal interspace, 12cm from the middle
line. There was a soft blowinglike systolic
murmur at the apex.
 Physical Examination

Abdominal wall was soft without

tenderness. The liver was not palpable.
There was obvious pitting edema in both
lower extremities.
 Question 5
• About the contents of physical examination,
do you have anything to add?
 Physical Examination
Physical Examination: T.36.8℃, P.96/min,
R28/min,Bp 102/76mmHg. He was mentally
normal and cooperative in the examination.
he was lying in bed with a semi-lying
position. He looked cyanosis in lip. There
was no edema in the eyelids and face. The
neck was soft, there was distention of
jugular vein. Thyroid glands were not
palpable, there were no thrill.
 Physical Examination
The chest and respiratory movements were
rapid. There was dullness to percussion at
right lower lung. Some moist rales were
heard in the whole areas of bilateral lungs.
 Physical Examination
The heart rate was 120/min, regular,. The point
of apex impulse was visible in the 5th costal
interspace, 12cm from the middle line. There
was a soft blowinglike systolic murmur at the
apex. There was eliminated S1, obvious
prorodiastolic S3 gallop and increased P2.
 Physical Examination
Abdominal wall was soft without tenderness.
The liver was not palpable. There was no
shifting dullness.There was obvious pitting
edema in both lower extremities.
 Question 6
• Next step, which laboratory and diagnostic
test should be done?
Electrocardiography
Echocardiography
Chest X-ray
Chest X-ray
Chest X-ray
The blood count
Renal function tests and Serum lectrolytes
Serum B-type natriuretic peptide
Serum CTnI
Thyroid function examination
 Question 7
• How to determine the place for the
treatment?
• The outpatient clinic or hospitalization?
 Question 8

• How about the pharmacological therapy?