🤔 MEDIUM

Here is the first of two questions on oedema.  A bit like that scene in the Harry Potter book where the muggle expands and floats off (hence the balloons).  There are two to choose from and here is one of them … good luck!

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oedema 2

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Question 1
A 77 year old female patient presents to her GP with a swollen and red forearm. The limb is hot, tender and there is a notable puncture wound. The red region is poorly demarcated and covers about two palms. Her medical history is notable for allergy to warfarin, atorvastatin and penicillin. She has controlled atrial fibrillation, GORD and diverticulosis.
Given the best matched differential, which is the most appropriate first line therapy?
A
Amoxicillin
B
Co-amoxiclav
C
Doxycycline
D
Flucloxacillin
E
Piperacillin
Question 1 Explanation: 
Uncomplicated cellulitis can be treated with PO flucloxacillin first line. If the patient is allergic to penicillin it can be swapped out for PO doxycyclin.
Question 2

Stem 1 of 10

An 82 year-old man presents with difficulty in breathing after walking up a flight of stairs in town today. He is “terribly” wheezing and complains of fatigue. This he puts down to lack of sleep because “I keep waking up gasping for breath! Its so scary!”. On examination his peripheries are cold, SBP95, apex is felt closer to the anterior axillary fold than midclavicular. His BMI is 21.
Which of the below descriptions best define the anterior axillary fold?
A
Contains a muscle innervated by the dorsal scapular n
B
Contains a muscle innervated by the latissimus dorsi n
C
Contains a muscle innervated by the long thoracic n
D
Contains a muscle innervated by the medial pectoral n
E
Contains a muscle innervated by the phrenic n
Question 3

Stem 2 of 10

How is ejection fraction calculated?
A
CO x HR
B
EDV / SV
C
HR x SV
D
SV / EDV
E
SV / SVR
Question 4

Stem 3 of 10

To classify this patient as systolic heart failure, which ejection fraction is most appropriate?
A
<60
B
<55
C
<50
D
<45
E
<40
Question 5

Stem 4 of 10

Calculate his New York Classification of Heart Failure
A
I
B
II
C
III
D
IV
E
V
Question 5 Explanation: 
The patient can be described as having less than ordinary activity causing DIB which is affecting daily living. NYCHF is rated grades I-IV.
Question 6

Stem 5 of 10

According to NICE, what is/are the first line investigation(s) in this patient?
A
ANP
B
BNP
C
CXR
D
D-Dimer
E
ECG
F
TOE
G
Troponin
H
TTE
Question 6 Explanation: 
According to NICE (2017), ECG and BNP first line are indicated in ?HF patients. If both are normal, HF is unlikely and other differentials should be worked up.
Question 7

Stem 6 of 10

As per the previous question, labs are requested. They are positive. What is the next best step for this patient?
A
ANP
B
CXR
C
D-Dimer
D
TOE
E
Troponin
F
TTE
Question 7 Explanation: 
NICE 2017 state the best diagnostic investigation for HF, once ECG and BNP have returned abnormal findings, is to undertake an echo.
Question 8

Stem 7 of 10

Which of the following would you least expect on chest X-ray in this patient?
A
57% cardiothoracic ratio
B
Apical opacities
C
Diversion of blood to apices
D
Perihilar shadowing
E
Septal/Kerley B lines
Question 9

Stem 8 of 10

Which of the following best describes the lab test BNP?
A
Increased VQ ratio is unlikely to cause BNP elevation
B
BNP is one of the most sensitive biomarkers of heart failure
C
BNP decreases glomerular filtration rate
D
Sudden cardiac arrest risk is proportional to pro-BNP in serum
E
The release of BNP is related to increased preload
Question 9 Explanation: 
BNP is a natriuretic peptide released mostly by the ventricles in response to increased stretch (EDV). It causes natriuresis, increasing eGFR and thus lowering the volume of the blood. It is both 90% sensitive and 90% specific for discerning DIB differential for heart failure and its serum volume is directly proportional to the severity of the disease. PE - causing a perfusion failure of gaseous exchange and thus raising VQ ratio - does cause elevated BNP, alongside systemic infection, tachycardia and other cardiac disease. An ECG and BNP should be undertaken in the ?HF patient, and if results are abnormal send for a fuller work up including gold-standard diagnostic TTE/TOE.
Question 10

Stem 9 of 10

The patient is started on medication. Of the choices below, select the two that are true.
A
A contraindication for digoxin is atrial fibrillation
B
Hydralazine can be paired with ISMN for second line therapy
C
If patient is still symptomatic after ACEi and BB, consider thiazide
D
Beta blockers do not improve mortality
E
Ramipril improves symptoms and mortality
Question 10 Explanation: 
The heart failure patient should be started on an ACEi and a cardioselective beta blocker (eg ramipril and carvedilol). These act synergistically to improve symptoms and prolong life. If the patient remains symptomatic, a K+ sparing mineralocorticoid antagonist can be added to this treatment regimen (e.g. spironolactone or eplerenone). Consider hydralazine and ISMN dual-therapy to decrease systemic vascular resistance as a second-line adjunct. Digoxin is given to heart failure patients with atrial fibrillation and thus it is not a contraindication at all!
Question 11

Stem 10 of 10

Which three of the following medications should be avoided in this patient?
A
Carbonic anhydrase inhibitors
B
Class four anti-arrhythmics
C
NaCl early DCT antagonists
D
Oxyntic cell direct inhibitors
E
Selective COX2 inhibitors
Question 11 Explanation: 
NSAIDs, verapamil and thiazides should be avoided in heart failure patients where possible as they respectively: increase fluid retention, are negatively inotropic and cause dangerous K+ levels.
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