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IM1.1-27 | Heart Failure — Assignment
CLINICAL SCENARIO
This assignment requires you to produce a comprehensive structured clinical case report and management plan for a patient with heart failure. You may use a real patient you have clerked during your General Medicine posting (de-identified), or construct a composite clinical case based on your SDL learning. The report should demonstrate your ability to classify heart failure, integrate clinical and investigative findings, and develop an evidence-based, individualised management plan.
Instructions
Write a structured clinical case report in the five sections below. Use clear, professional clinical language. All drug class names must be used correctly; where you name a specific drug as an example, ensure the dose range and key contraindication are cited. Do not copy SDL content verbatim — synthesise and apply the knowledge to your patient. Word limit: 1,200–1,600 words. De-identify any real patient data completely before submission (replace name with initials, remove registration number, use approximate age).
Length: 1,200–1,600 words across all sections
What to Submit
Section 1: History and Classification
Guidance: Present a structured history: presenting complaint, duration and progression of symptoms, functional limitations (state the NYHA class explicitly and justify it), precipitating and exacerbating factors (list each separately — e.g., non-compliance, new AF, intercurrent infection, NSAID use), past cardiac history, drug history (including current medications and any nephrotoxic or cardiotoxic drugs), relevant social history. State the LVEF category (HFrEF, HFmrEF, or HFpEF) with the exact LVEF value if available and the threshold used. Approximately 300 words.
Section 2: Physical Examination and Differential Diagnosis
Guidance: Document the cardiovascular examination findings systematically: general inspection, pulse, blood pressure, JVP (method and height above sternal angle), apex beat (location and character), heart sounds and added sounds (state whether S3 or S4 is present and its haemodynamic meaning), murmurs (timing, site, radiation, dynamic variation if relevant), and peripheral examination (ankle oedema, sacral oedema, hepatomegaly, ascites, cyanosis, clubbing). For each significant positive finding, state its haemodynamic significance in one sentence. Construct a prioritised differential diagnosis with at least three diagnoses and your clinical reasoning. Approximately 300 words.
Section 3: Investigation Interpretation
Guidance: Select and interpret the appropriate investigation bundle. For each investigation, state the expected finding in this patient AND its clinical significance: (a) 12-lead ECG: describe and interpret the rhythm, conduction, and any LVH/ischaemia pattern; (b) Chest radiograph: describe cardiomegaly, pulmonary venous redistribution, Kerley B lines, pleural effusions; (c) BNP or NT-proBNP: state the expected level and the diagnostic threshold (BNP above 35 pg/mL or NT-proBNP above 125 pg/mL); (d) 2D echocardiogram: state LVEF, wall motion, valvular pathology, and Doppler indices of diastolic function if available. Mention any additional investigations justified by the suspected aetiology (e.g., coronary angiogram for ischaemic HF, thyroid function for thyrotoxic precipitant). Approximately 300 words.
Section 4: Management Plan
Guidance: Structure your plan as: (a) Address the precipitant — if one was identified, state how it is corrected; (b) Non-pharmacological management: sodium restriction target (below 2 g/day), fluid restriction if indicated, daily weight monitoring protocol, graded aerobic exercise for stable patients, smoking cessation, alcohol reduction; (c) Pharmacotherapy for HFrEF (if applicable): list all four evidence-based pillars with drug class, example drug, rationale, key contraindications, and monitoring required for each — ACE inhibitor/ARB/ARNI, beta-blocker, aldosterone antagonist, SGLT2 inhibitor; for HFpEF management, address the symptom-management approach and comorbidity control; (d) Monitoring plan: renal function, electrolytes, weight, functional class, repeat echocardiogram timeline; (e) Surgical/device referral: state whether criteria for CRT, ICD, valvular intervention, or transplant assessment are met in this patient and why. Approximately 400 words.
Section 5: Clinical Reasoning and Integration
Guidance: Write a concluding integrative paragraph (approximately 150 words) that connects the aetiology to the clinical presentation, the investigation findings, and the management choices. Explain why the specific aetiology of heart failure in your patient determines which pharmacological or surgical interventions are prioritised. Comment on the prognosis in terms of NYHA class, LVEF, and response to therapy. This section should read as a clinical narrative, not a list.
Grading Rubric — Heart Failure Case Report Rubric
| Criterion | Points | Full-marks descriptor |
|---|---|---|
| History and Classification (Section 1): Elicits a structured, complete history addressing presenting complaints, functional class, precipitating and exacerbating factors, risk factors, and features of specific aetiology; correctly classifies the heart failure by LVEF category and NYHA class. | 20 pts | History is complete and systematically organised; all major domains covered (presenting complaint, functional impairment with NYHA class stated, precipitants, risk factors, relevant drug history, social factors); LVEF category correctly stated with exact threshold cited; NYHA class correctly assigned with justification. |
| Physical Examination and Differential Diagnosis (Section 2): Documents a systematic cardiovascular examination with findings mapped to haemodynamic significance; generates a differential diagnosis prioritised by likelihood with supporting clinical reasoning. | 20 pts | Examination findings described with haemodynamic significance (e.g., S3 gallop indicates elevated filling pressures; displaced apex beat indicates LV dilation; raised JVP indicates right heart congestion); differential diagnosis lists at least 3 diagnoses with the most likely first and clinical reasoning for prioritisation. |
| Investigation Interpretation (Section 3): Selects and interprets the appropriate investigation bundle for heart failure; correctly interprets ECG, chest radiograph, BNP/NT-proBNP, and echocardiographic findings in relation to the clinical diagnosis. | 20 pts | Investigation bundle is complete and justified; ECG findings correctly interpreted with haemodynamic significance (e.g., LVH, LBBB, AF); CXR findings correctly described (cardiomegaly, redistribution, Kerley B lines, pleural effusion); BNP threshold cited accurately (above 35 pg/mL supports HF); echocardiographic LVEF and Doppler findings interpreted correctly with reference to HFrEF/HFmrEF/HFpEF classification. |
| Management Plan (Section 4): Develops a structured, individualised management plan encompassing non-pharmacological measures, pharmacotherapy (with drug class, rationale, contraindications, and monitoring), and identification of surgical or device indications if applicable. | 30 pts | Non-pharmacological management correctly described (sodium below 2 g/day, fluid restriction if applicable, daily weight monitoring, physical activity guidance, smoking cessation, alcohol reduction); pharmacotherapy includes all four evidence-based pillars for HFrEF (ACE inhibitor/ARB/ARNI, beta-blocker, aldosterone antagonist, SGLT2 inhibitor) with rationale and key contraindications cited; monitoring plan includes serum electrolytes, renal function, and dose titration; precipitant addressed if identified; surgical/device indication correctly assessed. |
| Clinical Reasoning and Integration (Section 5): Demonstrates integration of history, examination, and investigation findings into a coherent clinical narrative; identifies the most likely aetiology and explains how this determines treatment choice and prognosis. | 10 pts | Narrative integrates all three domains; aetiology identified and linked explicitly to treatment selection (e.g., ischaemic HFrEF justifies revascularisation assessment; rheumatic valvular HF justifies valvuloplasty/replacement consideration; hypertensive HFpEF justifies BP control and diuresis); prognosis discussed with reference to NYHA class or LVEF. |
PEER REVIEW
Review your peer's case report using the rubric. For each criterion, assign a score and write one specific comment explaining your assessment — do not simply copy the rubric descriptor. Pay particular attention to: (a) Section 1 — verify that the LVEF threshold used for classification is exact (HFrEF = 40% or less, HFmrEF = 41-49%, HFpEF = 50% or greater) and that the NYHA class is justified by the functional description given; (b) Section 4 — verify that spironolactone monitoring (serum potassium and renal function) is mentioned and that the student does not apply the mechanical mitral valve INR target (2.5-3.5) when only AF is present (should be 2-3). Complete your peer review within 72 hours.