Cardiovascular · Moderate
This case is fictional and exists for study. It describes no real patient.
68 years · male
A 68-year-old male presents to the acute medical clinic with a 3-week history of worsening shortness of breath on exertion, which now occurs with minimal activity. He reports waking up at night gasping for air and requires three pillows to sleep comfortably. Over the past month, he has noticed swelling in both legs extending up to his mid-calves. His past medical history includes hypertension and an anterior myocardial infarction two years ago. On examination, he is mildly tachypnoeic at rest. Auscultation reveals bilateral fine crackles at the lung bases. Cardiovascular examination demonstrates a jugular venous pressure elevated 4 cm above the sternal angle and a third heart sound (S3). Bilateral pitting ankle oedema is present.
Vital signs
- HR
- 92 bpm
- BP
- 138/84 mmHg
- RR
- 22/min
- Temp
- 36.8 °C
- SpO₂
- 93%
Examination findings
- Elevated jugular venous pressure (4 cm above sternal angle)
- Bilateral basal crackles on lung auscultation
- Presence of a third heart sound (S3)
- Bilateral pitting pedal oedema to mid-calf
Investigations
| B-type natriuretic peptide (BNP) | 850 pg/mL | reference: < 100 |
| Haemoglobin | 13.5 g/dL | reference: 13.0-17.0 |
| Serum creatinine | 110 µmol/L | reference: 60-110 |
| Serum potassium | 4.4 mmol/L | reference: 3.5-5.0 |
Question 1 of 3
Which of the following is the most likely diagnosis?
Congestive heart failure is the most likely diagnosis given the classic presentation of orthopnoea, paroxysmal nocturnal dyspnoea, bilateral pedal oedema, raised JVP, bilateral lung crackles, an S3 gallop, and significantly elevated BNP levels in a patient with a prior myocardial infarction. Acute pulmonary embolism typically presents with sudden-onset dyspnoea and pleuritic chest pain rather than subacute fluid overload. COPD exacerbation presents primarily with wheeze and productive cough, without S3 or markedly elevated BNP. Nephrotic syndrome causes generalized oedema and proteinuria but does not explain the S3 gallop or previous cardiac history.
Teaching point: Elevated BNP combined with symptoms of fluid congestion and a elevated JVP strongly points toward heart failure.
Question 2 of 3
Which of the following is the next best investigation to assess left ventricular ejection fraction and confirm cardiac structure and function?
Transthoracic echocardiography (TTE) is the primary diagnostic imaging modality recommended to evaluate cardiac structure, chamber sizes, and left ventricular ejection fraction (LVEF) in patients with suspected heart failure. CT coronary angiography is used to evaluate coronary artery disease rather than cardiac function. HRCT of the chest is used to assess interstitial lung disease. Cardiac MRI is useful for detailed tissue characterization or when TTE is non-diagnostic, but it is not the initial test of choice.
Teaching point: Transthoracic echocardiography is the key initial investigation to confirm diagnosis, assess LVEF, and identify structural heart disease in suspected heart failure.
Question 3 of 3
Which of the following is the most appropriate initial management step to relieve the patient's acute symptoms of fluid overload?
Intravenous loop diuretics (such as furosemide) are the first-line therapy to achieve rapid symptom relief and decongestion in patients presenting with acute fluid overload secondary to decompensated heart failure. Oral spironolactone and ACE inhibitors are cornerstone chronic disease-modifying therapies for heart failure with reduced ejection fraction, but they do not provide immediate rapid decongestion. Intravenous beta-blockers are contraindicated in acute decompensated heart failure due to their negative inotropic effects, which can worsen cardiac function.
Teaching point: Intravenous loop diuretics are the first-line intervention for rapid decongestion and symptom relief in acute decompensated heart failure.
Key learning points
- Orthopnoea, paroxysmal nocturnal dyspnoea, raised JVP, S3 gallop, and elevated BNP are hallmark features of congestive heart failure.
- Transthoracic echocardiogram is the essential initial diagnostic test to evaluate ventricular function and structural abnormalities.
- Intravenous loop diuretics are the mainstay of initial treatment for acute symptom relief in patients with fluid overload.
This is one of 158 free cases
AskPreceptor is a study tool for medical students: answer first, then see the reasoning — including why each wrong option is wrong. Free, no sign-up required.