Echo Cases

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Mr. Joseph is a 65-year-old man from the village of Boucan Ferdinand who was brought to the hospital by his son. His son describes that he has been suffering from shortness of breath ("souf kout") for a few days, but he didn't want to go to the hospital and tried to treat himself using his old family remedy made of honey, Aloe Vera, and almond leaves. Mr. Joseph says that his symptoms are caused by "evil spirits" and doesn't seek medical care unless it's a life-or-death situation. He also says that yesterday he was coughing during the night and couldn't sleep. <img style='width: 100%' src="https://images2.imgbox.com/cb/48/6PHqRZKz_o.jpg"> /* Diagnostic choices booleans. */ <<silently>> <<set $physical_exam_1 to false>> <<set $EKG_1 to false>> <<set $CXR_1 to false>> <<set $Labs_1 to false>> <<set $Echo_1 to false>> <<set $reprimand_1 to 0>> <</silently>> /* First part is displayed, second part is the passage name. */ What is your first step in the assessment? [[Physical examination|Physical Exam 1]] [[EKG|EKG 1]] [[Chest X-ray|Chest X-Ray 1]] [[Laboratory tests|Labs 1]] [[Echo|Echo 1]] <<silently>> /* Scoring variables start at 0. One each for Treatment, Follow up and Echo. */ <<set $case_1_Tx_score to 0>> <<set $case_1_Fu_score to 0>> <<set $case_1_Echo to 0>> <<set $echo1_quiz to [0, 0, 0, 0, 0, 0]>> <</silently>> /* Case stare is the intermediate step after each diagnosis choice, instead of showing the original case presentation. Plus it shows some notes for quick review. */

What is your next step? [[Physical examination|Physical Exam 1]] [[EKG|EKG 1]] [[Chest X-ray|Chest X-Ray 1]] [[Laboratory tests|Labs 1]] [[Echo|Echo 1]] /* If the correct workup has been done, move on to treatment. Otherwise reprimand. */ <<if hasVisited("EKG 1", "Echo 1", "Physical Exam 1")>> [[Continue to treatment|Treatment 1]] <<else>> [[Continue to treatment|Not done Dx yet 1]] <</if>> Notes: 65-year-old man with worsening dyspnea. History of hypertension, hyperlipidemia, smoking, suspected ACS 5 years ago. Clinical assessment: BP 110/70, HR 120 bpm, RR 24 rpm, O2 sat 94% on room air /* Start of the workup choices code.*/

You begin a physical examination of the patient. You notice jugular venous distention, a third heart sound, pulmonary crackles, and hepatojugular reflux. <img style='width: 100%' src="https://th.bing.com/th/id/OIG.0cQhitmVDNPrEFUpfOiG?pid=ImgGn"> /* Keep track for scoring purposes later. */ <<set $physical_exam_1 to true>> [[Continue|Case stare 1]]

His electrocardiogram showed sinus tachycardia and Q waves in the inferior leads. <img style='width: 100%' src="https://www.researchgate.net/publication/270131476/figure/fig1/AS:406690156564480@1473973897767/Electrocardiogram-showing-sinus-rhythm-normal-axis-Q-waves-in-lead-3-and-AvF-diagnostic.png"> <<set $EKG_1 to true>> [[Continue|Case stare 1]]

40 minutes later, the radiologist gives you the following film with a signed note that says: Name: H. F. Age: 65 years Gender: Male Modality: Chest X-ray CXR reveals bilateral pulmonary edema - diffuse opacification of both lung fields with prominence of interstitial markings. Slightly enlarged cardiac silhouette. Clinical correlation advised. <<set $CXR_1 to true>> <img style='width:100' src="https://upload.wikimedia.org/wikipedia/commons/thumb/7/75/Pulmonary_oedema.jpg/220px-Pulmonary_oedema.jpg"> [[Continue|Case stare 1]]

Laboratory tests showed a Hg level of 10.3 mg/dL. Renal function, liver function, and blood glucose values returned normal. <img style='width: 100%' src="https://th.bing.com/th/id/OIG.XplZfSqT4XtsyDX61Woz?pid=ImgGn"> <<set $Labs_1 to true>> [[Continue|Case stare 1]]

The echocardiogram is illustrated below: <img src="https://images.squarespace-cdn.com/content/v1/5c69e7d7b91449698da66e65/1594584852856-Z6Q0VS5GJDF97ZWY648R/PSL.ezgif.gif?format=1500w"> What is the echocardiographic view? <label><<radiobutton "$echo1_quiz[0]" 1 autocheck >> Parasternal long axis </label> <label><<radiobutton "$echo1_quiz[0]" 2 autocheck >> Parasternal short axis </label> <label><<radiobutton "$echo1_quiz[0]" 3 autocheck >> Apical 4-chamber </label> <label><<radiobutton "$echo1_quiz[0]" 4 autocheck >> Apical 2-chamber </label> <label><<radiobutton "$echo1_quiz[0]" 5 autocheck >> Subxiphoid </label> <img src="https://images.squarespace-cdn.com/content/v1/5c69e7d7b91449698da66e65/1594584918045-SSY2ASB8VE4X1CCB4SH7/PSS.ezgif.gif?format=1500w"> What is the echocardiographic view? <label><<radiobutton "$echo1_quiz[1]" 1 autocheck >> Parasternal long axis </label> <label><<radiobutton "$echo1_quiz[1]" 2 autocheck >> Parasternal short axis </label> <label><<radiobutton "$echo1_quiz[1]" 3 autocheck >> Apical 4-chamber </label> <label><<radiobutton "$echo1_quiz[1]" 4 autocheck >> Apical 2-chamber </label> <label><<radiobutton "$echo1_quiz[1]" 5 autocheck >> Subcostal inferior vena cava view </label> <img src="https://images.squarespace-cdn.com/content/v1/5c69e7d7b91449698da66e65/1594584995311-FAYVYD8C966A4DV43DJW/A4C.ezgif.gif?format=1500w"> What is the echocardiographic view? <label><<radiobutton "$echo1_quiz[2]" 1 autocheck >> Parasternal long axis </label> <label><<radiobutton "$echo1_quiz[2]" 2 autocheck >> Parasternal short axis </label> <label><<radiobutton "$echo1_quiz[2]" 3 autocheck >> Apical 4-chamber </label> <label><<radiobutton "$echo1_quiz[2]" 4 autocheck >> Apical 2-chamber </label> <label><<radiobutton "$echo1_quiz[2]" 5 autocheck >> Subxiphoid </label> How is this view obtained in echocardiography? <label><<radiobutton "$echo1_quiz[5]" 1 autocheck>> Place the transducer in the parasternal window with the transducer index mark oriented toward the patient's right shoulder (10 o'clock) in the third or fourth intercostal space. </label> <label><<radiobutton "$echo1_quiz[5]" 2 autocheck>> Place the transducer in the fourth or fifth left parasternal intercostal space in a line connecting the left clavicle/shoulder and right hip, with the transducer rotated 90 degrees clockwise from the parasternal long axis view. </label> <label><<radiobutton "$echo1_quiz[5]" 3 autocheck>> Place the transducer at the point of maximal impulse with the indicator pointing to the patient's left side. </label> <label><<radiobutton "$echo1_quiz[5]" 4 autocheck>> Place the transducer on the patient's abdomen in the subcostal region, slightly to the right of the midline. The transducer index mark is oriented toward the patient's left, at the 3 o'clock position. </label> <label><<radiobutton "$echo1_quiz[5]" 5 autocheck>> Place the transducer in the subxiphoid window with the orientation mark toward the patient's head and slightly angled toward the patient's right. </label> <img src="https://images.squarespace-cdn.com/content/v1/5c69e7d7b91449698da66e65/1594585189558-U9GYSKSZZ9NQ74QGG6M5/IVC.ezgif.gif?format=1500w"> What is the echocardiographic view? <label><<radiobutton "$echo1_quiz[3]" 1 autocheck >> Parasternal long axis </label> <label><<radiobutton "$echo1_quiz[3]" 2 autocheck >> Parasternal short axis </label> <label><<radiobutton "$echo1_quiz[3]" 3 autocheck >> Apical 4-chamber </label> <label><<radiobutton "$echo1_quiz[3]" 4 autocheck >> Apical 2-chamber </label> <label><<radiobutton "$echo1_quiz[3]" 5 autocheck >> Subcostal inferior vena cava view </label> What do you think of the LV Ejection Fraction? <label><<radiobutton "$echo1_quiz[4]" 1 autocheck >> Reduced ejection fraction (<40%) </label> <label><<radiobutton "$echo1_quiz[4]" 2 autocheck >> Mildly reduced ejection fraction (40-49%) </label> <label><<radiobutton "$echo1_quiz[4]" 3 autocheck >> Preserved ejection fraction (≥50%) </label> What do you think the echo shows? <label><<radiobutton "$case_1_Echo" 1 autocheck>> Dilated inferior vena cava and severely reduced ejection fraction </label> <label><<radiobutton "$case_1_Echo" 2 autocheck>> Preserved ejection fraction and dilated but compliant inferior vena cava </label> <label><<radiobutton "$case_1_Echo" 3 autocheck>> Mitral valve prolapse and left atrial dilation </label> Please answer all questions before continuing. <<repeat 0.2s>><<if ($echo1_quiz[0] * $echo1_quiz[1] * $echo1_quiz[2] * $echo1_quiz[3] * $echo1_quiz[4] * $echo1_quiz[5] * $case_1_Echo)>> [[Continue|Case stare 1]]<<stop>><</if>><</repeat>> /* Reprimand and return to diagnostic evaluation. Don't need to remove points here, you can see if they got here through the history later. */

The consulting cardiologist tells you that you need some additional diagnostic steps before moving on to treatment. <<set $reprimand_2 += 1>> <img style='width: 100%' src="https://th.bing.com/th/id/OIG.GT2Nb_vjvLKVbfInIsT4?pid=ImgGn&rs=1"> [[Continue|Case stare 1]]

The echo report reads: "Left ventricular ejection fraction of 20%. Signs of moderate pulmonary hypertension and dilated inferior vena cava." <img style='width: 100%' src="https://th.bing.com/th/id/OIG.SkbRZFTP9J47INQByGlT?pid=ImgGn"> Remember that a physical examination is important when first approaching a patient. After that, an echocardiogram and an ECG are necessary diagnostic steps before moving on to treatment in this patient. <img style='width: 100%' src="https://th.bing.com/th/id/OIG.frL6vSaxNaetRJfhLhQt?pid=ImgGn"> The head nurse asks you which of the following would be the best initial treatment option for this patient: [[IV Furosemide|Furosemide IV 1]] [[Oral loop diuretic|Bad outcome 1]] [[1.5 L of Lactated Ringer's (no NaCl) and 10 mg of IV metoprolol|Very bad outcome 1]]

After starting high-dose IV furosemide, the patient reports improvement in symptoms. He is able to breathe better and lie flat. He thanks you. His blood pressure has normalized. IV furosemide is the correct first choice in the treatment of acute decompensated heart failure, according to international guidelines. <<set $case_1_Tx_score += 4 >> [[Continue|Further management 1]]

Mr. Joseph improves slowly over the following days. During his hospital stay, he still complains of dyspnea for the next five days "souf li wo" when trying to walk to the bathroom, although his peripheral edema seems to be slowly improving. On the 6th day, he is finally asymptomatic according to him. <img style='width: 100%' src="https://th.bing.com/th/id/OIG.X6JIXmdBt0K_GY8_8GVG?pid=ImgGn"> <<set $case_1_Tx_score += 3 >> [[Continue|Further management 1]]

3 hours later, you are called by the nurse because the patient "doesn't seem to be doing well." Mr. Joseph's blood pressure is 90/70 mmHg, his heart rate is 140 bpm, and his extremities are pale and cold to the touch. Mr. Joseph is admitted to intensive care for further management of heart failure with reduced ejection fraction complicated by cardiogenic shock. <img style='width: 100%' src="https://th.bing.com/th/id/OIG.ZCGoOne7gjb9cVeeQ5SV?pid=ImgGn&rs=1"> After 5 days in the intensive care unit, his symptoms and vital signs improve, and he is transferred back to the regular ward. <<set $case_1_Tx_score -= 4 >> [[Continue|Further management 1]]

You examine Mr. Joseph and discuss his symptoms with him. He reports that he feels better and no longer has "Pye anfle" (swollen feet). During the examination, you confirm that the edema has disappeared and lung sounds are normal. The attending physician comes to ask you what would be the next step in the management of Mr. Joseph. [[Discharge home on oral diuretics|Discharge home 1]] [[Keep in hospital for further management|Hospitalization and monitoring 1]]

According to guidelines, it is advised to hospitalize and monitor patients with acute decompensated heart failure. Oral diuretic treatment may not be sufficient to control their heart failure. Additionally, since this patient traveled a long way to the hospital, he may be lost to follow-up and needs to be put on heart failure treatment before leaving. <<set $case_1_Fu_score -= 5 >> [[Continue|Hospitalization and monitoring 1]]

Mr. Joseph stays in the hospital for more optimal management. You review and discuss with the medical team about chronic heart failure management. Mr. Joseph is put on ACE inhibitor, beta-blocker, spironolactone, and oral furosemide. Mr. Joseph also receives medical education sessions on how to take medications at home and help finding a primary care physician for long-term follow-up. <<set $case_1_Fu_score += 3 >> [[Continue|End of case 1]]

<img style='width: 100%' src="https://th.bing.com/th/id/OIG.QMlLg0S0P5J4GJQhjdAU?pid=ImgGn"> A month later, Mr. Joseph's son comes to the hospital to ask the nurse to see you. He holds in his hand a wooden sculpture representing a stethoscope and tells you: "My father is doing much better with the new medication. He told me to give you this as a gift to eliminate the evil spirits that were harming him, he made it for you. Thank you for helping him!" Congratulations! You have completed the first case! The main points of heart failure management are: After a physical examination, an ECG and an echocardiogram are necessary for the complete evaluation of suspected heart failure. A chest X-ray is less relevant if echocardiography is performed coupled with BNP testing. In the absence of these paraclinical examinations, it will help to check the condition of the lung parenchyma - detect cardiomegaly but does not rule out heart disease. The best first step in management is to administer intravenous furosemide. Oral furosemide should be considered if IV form is not available, but the expected response may be delayed. ''However, beta-blockers and IV fluids should be avoided in acute decompensated heart failure, as they can worsen the patient's condition and increase ICU admissions.'' After initial stabilization, patients should be put on long-term treatment for heart failure before leaving the hospital. This ensures they are adequately managed, given the risk they may be lost to follow-up due to difficulties accessing care. Early discharge or inadequate treatment (e.g., oral diuretics only) could lead to poorer outcomes. You can learn more about heart failure management by reading the 2021 European Society of Cardiology guidelines. [[2021 European Society of Cardiology guidelines|https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Acute-and-Chronic-Heart-Failure]]. [[Continue|Finish]]

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You might need headphones for an optimal experience. There is a diastolic murmur <audio controls> <source src="https://edge.sitecorecloud.io/mmanual-ssq1ci05/media/professional/sounds/aortic_stenosis_murmur.mp3" type="audio/mpeg"> Your browser does not support the audio element. </audio controls> <img style='width: 100%' src="https://images2.imgbox.com/dd/3f/fjpRaEYw_o.png"> What is the echocardiographic view? <label><<radiobutton "$echo3_quiz[3]" 1 autocheck >> Parasternal long axis </label> <label><<radiobutton "$echo3_quiz[3]" 2 autocheck >> Parasternal short axis </label> <label><<radiobutton "$echo3_quiz[3]" 3 autocheck >> Apical 4-chamber (Zoomed) </label> <label><<radiobutton "$echo3_quiz[3]" 4 autocheck >> Apical 2-chamber </label> <label><<radiobutton "$echo3_quiz[3]" 5 autocheck >> Subxiphoid </label> <label><<radiobutton "$echo3_quiz[3]" 6 autocheck >> Continuous wave Doppler </label>

Mulindwa, a 39-year-old businessman, presents to the emergency room with severe shortness of breath. He says he has had these symptoms for two months, but they have significantly worsened recently. When asked about his history, Mulindwa recalls that during his adolescence, he was once told that his blood pressure was slightly elevated, but no follow-up was done. He is overweight. Both his father and mother suffer from hypertension that manifested in their fifties. There are no other cardiac problems in the family. <img src="https://images2.imgbox.com/30/95/v8vkYeN0_o.jpeg"> At triage, Mulindwa's blood pressure is 180/95 mmHg in his right arm with a regular pulse of 90 bpm. His respiratory rate was 21 breaths/min with a SpO₂ of 93% on room air. His temperature was 36.2 degrees Celsius. What is your first step in the evaluation? [[Physical Exam|Physical Exam 2]] [[EKG|EKG 2]] [[Chest X-Ray|CXR 2]] [[Labs|Labs 2]] [[Echo|Echo 2]] <<silently>> <<set $case_2_Tx_score to 0>> <<set $case_2_Fu_score to 0>> <<set $echo2_quiz_view to 0>> <<set $echo2_quiz_view_2 to 0>> <<set $echo2_quiz_view_3 to 0>> <<set $echo2_quiz_ef to 0>> <<set $echo2_quiz_placement to 0>> /* Diagnostic scoring array: [0] for physical, [1] for EKG, [2] for CXR, [3] for Labs, [4] for Echo, [5] for reprimand. */ <<set $diagnostics_2_physical_exam to 0>> <<set $diagnostics_2_cxr to 0>> <<set $diagnostics_2_lab to 0>> <<set $diagnostics_2_ekg to 0>> <<set $diagnostics_2_echo_impression to 0>> <<set $diagnostics_2_reprimand to 0>> /* Case stare is the intermediate step after each diagnosis choice, instead of showing the original case presentation. Plus it shows only tests not already done yet and some notes for quick review. */ <</silently>>

What is your next step? [[Physical Exam|Physical Exam 2]] [[EKG|EKG 2]] [[Chest X-Ray|CXR 2]] [[Labs|Labs 2]] [[Echo|Echo 2]] <<if hasVisited("Labs 2", "Echo 2", "Physical Exam 2")>> [[Continue Treatment|Treatment 2]] <<else>> [[Continue Treatment|Not done Dx yet 2]] <</if>> /* This is where the diagnosis starts. */

Cardiac auscultation revealed mild crackles at both lung bases. There is no hepatomegaly, but you notice that his neck veins are distended. He also has pitting edema in the legs. <<set $diagnostics_2_physical_exam to 1>> [[Continue|Case stare 2]]

<img style='width: 100%' src="https://img.medscapestatic.com/pi/meds/ckb/89/34989tn.jpg"> <<set $diagnostics_2_cxr to 1>> [[I need to see the radiologist's report|Radiologist 2]] [[Continue|Case stare 2]]

The X-ray reveals cardiomegaly, signs of vascular redistribution, and pulmonary edema. Clinically correlates well. <img src="https://upload.wikimedia.org/wikipedia/commons/7/75/Pulmonary_oedema.jpg"> [[Continue|Case stare 2]]

<<set $diagnostics_2_lab to 1>> <img src="https://images.rawpixel.com/image_800/cHJpdmF0ZS9sci9pbWFnZXMvd2Vic2l0ZS8yMDIzLTAzL2ZsNTI2NzIxODE4NTctaW1hZ2UuanBn.jpg"> Laboratory tests showed a hemoglobin level of 11.5 g/dL Serum creatinine: 0.9 mg/dL Serum sodium: 140 mEq/L RBC: 6,700/ml WBC: 7,540/ml Platelets: 225,000/ml NT pro-BNP: 1600 pg/mL [[Continue|Case stare 2]]

<<set $diagnostics_2_ekg to 1>> <img style='width: 100%' src="https://www.wikidoc.org/images/f/f8/LVH_6.jpg"> [[Continue|Case stare 2]]

The cardiac echo is illustrated below and the septum measures 1.4 cm. <video controls autoplay src="https://mhp-assets.s3.amazonaws.com/echoatlas/videos/7_01c.mp4" frameborder="0" allowfullscreen></video> What is the echocardiographic view? <label><<radiobutton "$echo2_quiz_view" 1 autocheck>> Parasternal long axis </label> /*correct */ <label><<radiobutton "$echo2_quiz_view" 2 autocheck>> Parasternal short axis </label> <label><<radiobutton "$echo2_quiz_view" 3 autocheck>> Apical 4-chamber </label> <label><<radiobutton "$echo2_quiz_view" 4 autocheck>> Apical 2-chamber </label> <label><<radiobutton "$echo2_quiz_view" 5 autocheck>> Subxiphoid </label> <video controls autoplay src="https://mhp-assets.s3.amazonaws.com/echoatlas/videos/7_01a.mp4" frameborder="0" allowfullscreen></video> What is the echocardiographic view? <label><<radiobutton "$echo2_quiz_view_2" 1 autocheck>> Parasternal long axis </label> <label><<radiobutton "$echo2_quiz_view_2" 2 autocheck>> Parasternal short axis </label> <label><<radiobutton "$echo2_quiz_view_2" 3 autocheck>> Apical 4-chamber </label> /* correct */ <label><<radiobutton "$echo2_quiz_view_2" 4 autocheck>> Apical 2-chamber </label> <label><<radiobutton "$echo2_quiz_view_2" 5 autocheck>> Subxiphoid </label> How is this view obtained in ultrasound? <label><<radiobutton "$echo2_quiz_placement" 1 autocheck>> Place the transducer in the parasternal window with the transducer's index mark oriented toward the patient's right shoulder (10 o'clock) in the third or fourth intercostal space. </label> <label><<radiobutton "$echo2_quiz_placement" 2 autocheck>> Place the transducer in the left parasternal fourth or fifth intercostal space along a line connecting the left clavicle/shoulder and the right hip, with the transducer rotated 90 degrees clockwise relative to the long parasternal view. </label> <label><<radiobutton "$echo2_quiz_placement" 3 autocheck>> Place the transducer on the area of maximal pulse palpation with the indicator pointing toward the patient's left side. </label> /*correct */ <label><<radiobutton "$echo2_quiz_placement" 4 autocheck>> Place the transducer on the patient's abdomen in the subcostal region, slightly to the right of the midline. The transducer's index mark is oriented toward the patient's left, in the 3 o'clock position. </label> <label><<radiobutton "$echo2_quiz_placement" 5 autocheck>> Place the transducer in the subxiphoid window with the orientation mark toward the patient's head and slightly tilted to the patient's right </label> <video controls autoplay src="https://mhp-assets.s3.amazonaws.com/echoatlas/videos/7_01f.mp4" frameborder="0" allowfullscreen></video> What is the echocardiographic view? <label><<radiobutton "$echo2_quiz_view_3" 1 autocheck>> Parasternal long axis </label> <label><<radiobutton "$echo2_quiz_view_3" 2 autocheck>> Parasternal short axis </label> /*correct */ <label><<radiobutton "$echo2_quiz_view_3" 3 autocheck>> Apical 4-chamber </label> <label><<radiobutton "$echo2_quiz_view_3" 4 autocheck>> Apical 2-chamber </label> <label><<radiobutton "$echo2_quiz_view_3" 5 autocheck>> Subxiphoid </label> What do you think about the LV Ejection Fraction? <label><<radiobutton "$echo2_quiz_ef" 1 autocheck>> Reduced ejection fraction (<40%) </label> <label><<radiobutton "$echo2_quiz_ef" 2 autocheck>> Moderately reduced ejection fraction (40-49%) </label> <label><<radiobutton "$echo2_quiz_ef" 3 autocheck>> Preserved ejection fraction (≥50%) </label> /* correct */ /* Echo diagnosis choices. */ <<silently>> <<set $ddx_2_opinion to false>> <<set $ddx_2_HTeCM to false>> <<set $ddx_2_PICM to false>> <<set $ddx_2_AST to false>> <<set $ddx_2_SAP to false>> <<set $ddx_2_HTrCM to false>> <<set $ddx_2_score = 0>> <</silently>> The cardiac echo is illustrated below and the septum measures 1.4 cm. How would you describe the echo? <label><<radiobutton "$diagnostics_2_echo_impression" 1 autocheck>> Dilated cardiomyopathy </label> <label><<radiobutton "$diagnostics_2_echo_impression" 2 autocheck>> Aortic stenosis </label> <label><<radiobutton "$diagnostics_2_echo_impression" 3 autocheck>> Left ventricular hypertrophy </label> <label><<radiobutton "$diagnostics_2_echo_impression" 4 autocheck>> Rheumatic heart disease </label> Please answer all questions before continuing. <<repeat 0.2s>><<if ($echo2_quiz_view * $echo2_quiz_view_2 * $echo2_quiz_view_3 * $echo2_quiz_ef * $echo2_quiz_placement * $diagnostics_2_echo_impression)>> [[Continue|Diagnosis 2]]<<stop>><</if>><</repeat>> /* Reprimand and return to diagnostic evaluation. */

The consulting cardiologist tells you that you need a few more diagnostic steps before proceeding to treatment. <<set $diagnostics_2_reprimand += 1>> <img style='width: 100%' src="https://live.staticflickr.com/7137/7556644280_648eaa7dbe_b.jpg"> [[Continue|Case stare 2]]

/% Coronary artery disease, Hypertrophic cardiomyopathy, Pharmacogenic/Infective cardiomyopathy, aortic stenosis, sleep apnea, Hypertensive Cardiomyopathy. %/ <<silently>> <<set $ddx_2_opinion to false>> <<set $biggest_risk_2_htn to false>> <<set $biggest_risk_2_obes to false>> <<set $biggest_risk_2_diab to false>> <<set $biggest_risk_2_occ to false>> <</silently>> To your opinion, what is the correct diagnosis? <label><<radiobutton "$ddx_2_opinion" 1 autocheck>> Coronary artery disease </label> <label><<radiobutton "$ddx_2_opinion" 1 autocheck>> Heart failure with preserved ejection fraction </label> <label><<radiobutton "$ddx_2_opinion" 1 autocheck>> Heart failure with reduced ejection fraction </label> /* */ <label><<radiobutton "$ddx_2_opinion" 1 autocheck>> Rheumatic heart disease </label> <<set $biggest_risk_2 to false>> What is are the risk factors for this patient's diagnosis? <<checkbox "$biggest_risk_2_htn" false true>> Hypertension <<checkbox "$biggest_risk_2_obes" false true>> Obesity <<checkbox "$biggest_risk_2_diab" false true>> diabetes <<checkbox "$biggest_risk_2_occ" false true>> Occupation Please answer both questions before continuing. <<repeat 0.2s>><<if ($ddx_2_opinion and ($biggest_risk_2_htn or $biggest_risk_2_obes or $biggest_risk_2_diab or $biggest_risk_2_occ))>> [[Continue|Case stare 2]]<<stop>><</if>><</repeat>>

<img src="https://upload.wikimedia.org/wikipedia/commons/1/1d/Morbus_Fabry_LVH_echo_02.jpg"> A transthoracic echocardiogram (TTE) showed concentric left ventricular hypertrophy with preserved ejection fraction. The interventricular septum and posterior wall thickness was 14 mm. There were no signs of outflow tract obstruction. No significant valvular dysfunction was noted. Slight left atrial enlargement was observed. <<silently>> <<set $bp_control_2 to false>> <<set $diuretics_2 to false>> <<set $arbs_2 to false>> <<set $sglt_2 to false>> <<set $ace_arb_2 to false>> <<set $weight_control_2 to false>> <</silently>> Choose from the following medications those that you think would be part of the appropriate treatment. <<checkbox "$diuretics_2" false true>> Furosemide <<checkbox "$ace_arb_2" false true>> Angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (i.e. lisinopril, valsartan) <<checkbox "$arbs_2" false true>> aldosterone receptor antagonist (i.e. spironolactone ) <<checkbox "$sglt_2" to false true>> SGLT-2 inhibitor (empagliflozin or dapagliflozin) <<checkbox "$bp_control_2" to false true>> Blood pressure control <<checkbox "$weight_control_2" to false true>> Weight reduction Heart failure with preserved ejection fraction management relies on the management of the underlying issues like hypertension, obesity, abnormal rhythms like atrial fibrillation along with the management of patient symptoms. [[Continue|Guideline treatment 2]]

<img src="https://live.staticflickr.com/4164/33931804863_8e77bb1483_b.jpg"> <<silently>> <<if $bp_control_2>> <<set $case_2_Tx_score -= 4>> <</if>> <<if $diuretics_2>> <<set $case_2_Tx_score += 2>> <</if>> <<if $arbs_2>> <<set $case_2_Tx_score += 1>> <</if>> <<if $sglt_2>> <<set $case_2_Tx_score -= 2>> <</if>> <<if $ace_arb_2>> <<set $case_2_Tx_score += 4>> <</if>> <<if $weight_control_2>> <<set $case_2_Tx_score +=2>> <</if>> <</silently>> Thiazide diuretics, particularly chlorthalidone, are first-line for hypertension - diuretics are necessary for patients with resistant hypertensive disease. Angiotensin-converting enzyme inhibitors, ARBs are first-line in patients with diabetes or chronic kidney disease. !!!!!Class 1 (Evidence Proves Beneficial) # Diuretics (Loop/Thiazide): Provides symptom relief from congestion # BP Control (ACEi/ARB): Essential in hypertensive HFpEF # Exercise & Weight Loss: Improves function and quality of life !!!!!Class 2a (Strong Evidence Supporting Use) # SGLT2 inhibitors (Empagliflozin, Dapagliflozin): Reduce HF hospitalizations and improves quality of life # AF Management: Rate control or ablation Since Mulindwa is diabetic and overweight, angiotensin-converting enzyme inhibitors (ACE inhibitors) or ARBs are the best choice of medication treatment for him. If the patient were not diabetic, a calcium channel blocker, such as amlodipine, would have been the best choice, as this medication does not require close monitoring of potassium levels, creatinine, and blood pressure, unlike ACE inhibitors and ARBs. [[Continue|Outcome 2]]

<img src="https://images2.imgbox.com/93/8c/uSvY9104_o.jpeg"> Two weeks later, Mulindwa comes to the clinic to renew his prescription. He tells you that his dyspnea has improved and that he has no problems with the medications. Congratulations, you have completed the third case! Treatment of hypertensive cardiomyopathy focuses on controlling hypertension, as LVH does not directly benefit from pharmacotherapy. Patients with hypertensive cardiomyopathy should follow targeted heart failure treatment and use automatic blood pressure cuffs for home monitoring. ''A hypertensive medication exerts 75% of its maximum effect at only 50% of the maximum dose. Therefore, in patients whose blood pressure remains significantly elevated after starting an antihypertensive medication, adding another class of medications rather than increasing the dose may be more effective.'' /* Hypertension treatment algorithm: <img style='width: 100%' src="https://images2.imgbox.com/a9/10/9sBtQzqV_o.jpg"> */ [[AHA recommendations on hypertension treatment|https://academic.oup.com/view-large/186438663]] [[Statpearls book chapter on hypertensive heart diseases|https://www.ncbi.nlm.nih.gov/books/NBK539800/]] [[Move on to the final case|Case 1 introduction ]]

Kasozi is a 15-year-old teenage girl who lives in Kampala and comes to the hospital saying that she felt like she was suffocating during the night because of coughing and cannot sleep without 2 pillows for at least two weeks. She also has chest pain. She has been having fever and pain in her right knee, more than the left, for two days. After being asked, she remembers she had pain in her arm joints (elbows and shoulders) but she felt better with diclofenac, as well as having a recent throat cold. After trying everything she could, her best friend convinced her to come to the hospital in case there were medications that could help her. <img src="https://images2.imgbox.com/81/1c/TOW2S0C6_o.jpeg"> What is your first step in the evaluation? [[Physical Exam|Physical Exam 3]] [[EKG|EKG 3]] [[Chest X-Ray|Chest X-Ray 3]] [[Labs|Labs 3]] [[Echo|Echo 3]] /* Scoring variables start at 0. One each for Diagnosis, Treatment and Follow up. */ <<set $case_3_Tx_score to 0>> <<set $case_3_Fu_score to 0>> <<set $labs_most_suggestive_3 to 0>> <<set $echo3_quiz_view to 0>> <<set $echo3_quiz_view_2 to 0>> <<set $echo3_quiz_features to false>> <<set $echo3_quiz_ef to 0>> <<set $echo3_quiz_placement to 0>> /* Diagnostic scoring array: [0] for physical, [1] for EKG, [2] for CXR, [3] for Labs, [4] for Echo, [5] for reprimand. */ <<set $diagnostics_3_physical_exam to 0>> <<set $diagnostics_3_CXR to 0>> <<set $diagnostics_3_labs to 0>> <<set $diagnostics_3_ekg to 0>> <<set $diagnostics_3_reprimand to 0>> /* Case stare is the intermediate step after each diagnosis choice, instead of showing the original case presentation. Plus it shows only tests not already done yet and some notes for quick review. */

What is your next step? <img src="https://upload.wikimedia.org/wikipedia/commons/4/47/A_typical_examination_room_and_exam_table_in_a_doctor%27s_office._03.jpg"> [[Physical Exam|Physical Exam 3]] [[EKG|EKG 3]] [[Chest X-Ray|Chest X-Ray 3]] [[Labs|Labs 3]] [[Echo|Echo 3]] <<if hasVisited("Labs 3", "Echo 3", "Physical Exam 3")>> [[Continue Treatment|Treatment 3]] <<else>> [[Continue Treatment|Not done Dx yet 3]] <</if>> Notes: 15-year-old girl with dyspnea on minimal exertion worsening progressively and chest pain, along with joint pains. BP 140/90mmHg, HR 92 bpm, temperature 37.7°C, SpO₂ 94% on room air. /* Start of the workup choices. Trainee must pick "EKG" and "Echo" before the choice to move to treatment is actually open. If trainee chooses to move to treatment before that, he is reprimanded by the attending and loses one point in the score. Each choice either helps or hurts the trainee. Correct choices and incorrect choices are weighted so that picking all of them leads to a cancelling-out effect and the score is close to zero.*/

<<set $diagnostics_3_physical_exam to 1>> You begin a physical examination of the patient. Physical Exam: There is a diastolic heart murmur. On pulmonary auscultation, you hear significant crackles at both bases; the abdominal exam is normal; there is slight edema of the lower limbs, and the pulse is normal. There is right knee tenderness, with no significant swelling. There are small, tough nodules on the arms. Neurological examination is normal. She does not have a fever. [[Continue|Case stare 3]]

<<set $diagnostics_3_CXR>> 40 minutes later, the nurse hands you the following radiographic film: <img style='width: 100%' src="https://upload.wikimedia.org/wikipedia/commons/6/6d/16-01-Lungenoedem.png"> Bilateral patchy long infiltrates consistent with pulmonary edema. [[I need to see the radiologist's report|radiologist 3]] [[Continue| Case stare 3]]

Mild pulmonary edema. Mild atrial enlargement. <img src="https://upload.wikimedia.org/wikipedia/commons/6/6d/16-01-Lungenoedem.png> [[Continue|Case stare 3]]

<<set $diagnostics_3_labs to 1>> Hb level of 12 mg/dL. Otherwise, the rest of the available tests are normal, including CXR, Malaria (smear and rapid test), HSAg, CBC, RFP, UA, HIV, Syphilis, G/C, Typhoid. <img src="https://cdn2.picryl.com/photo/2017/02/06/blood-pumps-into-test-tubes-during-the-armed-services-74731e-1024.jpg"> NT pro-BNP at 1200 pg/mL Creatinine 1.0 mg/dL Hg 14 g/dL WBC: 5000/mL Which of the patient's lab findings is most suggestive of the diagnosis? <label><<radiobutton "$labs_most_suggestive_3" 1 autocheck >> NT pro-BNP </label> /* Correct */ <label><<radiobutton "$labs_most_suggestive_3" 2 autocheck >> Creatinine </label> <label><<radiobutton "$labs_most_suggestive_3" 3 autocheck >> Hemoglobin </label> <label><<radiobutton "$labs_most_suggestive_3" 4 autocheck >> White Blood Cells </label> [[Continue|Case stare 3]]

The ekg is notable for left atrial enlargement Note the deeply inverted P wave in V1 and wide P wave in II, greater than 120ms. <img style='width: 100%' src="https://www.ecgstampede.com/wp-content/uploads/2022/11/150-HCM_LAE-1-scaled.jpg"> <<set $diagnostics_3_ekg>> [[Continue| Case stare 3]]

The cardiac echo is illustrated below: <img src="https://mhp-assets.s3.amazonaws.com/echoatlas/videos/3_18a.png"> What is the echocardiographic view? /* Apical 4-chamber and doppler ultrasound */ <label><<radiobutton "$echo3_quiz_view" 1 autocheck >> Parasternal long axis </label> <label><<radiobutton "$echo3_quiz_view" 2 autocheck >> Parasternal short axis </label> <label><<radiobutton "$echo3_quiz_view" 3 autocheck >> Apical 4-chamber and Doppler ultrasound </label> <label><<radiobutton "$echo3_quiz_view" 4 autocheck >> Apical 2-chamber </label> <label><<radiobutton "$echo3_quiz_view" 5 autocheck >> Subxiphoid </label> <video controls autoplay src="https://mhp-assets.s3.amazonaws.com/echoatlas/videos/3_19a.mp4" frameborder="0" allowfullscreen></video> What is the echocardiographic view? /* Parasternal long axis */ <label><<radiobutton "$echo3_quiz_view_2" 1 autocheck >> Parasternal long axis </label> <label><<radiobutton "$echo3_quiz_view_2" 2 autocheck >> Parasternal short axis </label> <label><<radiobutton "$echo3_quiz_view_2" 3 autocheck >> Apical 4-chamber </label> <label><<radiobutton "$echo3_quiz_view_2" 4 autocheck >> Apical 2-chamber </label> <label><<radiobutton "$echo3_quiz_view_2" 5 autocheck >> Subxiphoid </label> Select the features you see in this video that can help you make a diagnosis? <<checkbox "$echo3_quiz_features" false true>> Reduced left ventricular ejection fraction <<checkbox "$echo3_quiz_features" false true>> Pericardial effusion <<checkbox "$echo3_quiz_features" false true>> Restricted opening and doming of the mitral valve /* Correct */ <<checkbox "$echo3_quiz_features" false true>> Normal findings overall <<checkbox "$echo3_quiz_features" false true>> Dilated left atrium /* Also correct */ How is this view obtained in ultrasound? <label><<radiobutton "$echo3_quiz_placement" 1 autocheck>> Place the transducer in the parasternal window with the transducer's index mark oriented toward the patient's right shoulder (10 o'clock) in the third or fourth intercostal space </label> <label><<radiobutton "$echo3_quiz_placement" 2 autocheck>> Place the transducer in the left parasternal fourth or fifth intercostal space along a line connecting the left clavicle/shoulder and the right hip, with the transducer rotated 90 degrees clockwise relative to the long parasternal view. </label> <label><<radiobutton "$echo3_quiz_placement" 3 autocheck>> Place the transducer on the area of maximum pulse palpation with the indicator pointing toward the patient's left side. </label> <label><<radiobutton "$echo3_quiz_placement" 4 autocheck>> Place the transducer on the patient's abdomen in the subcostal region, slightly to the right of the midline. The transducer's index mark is oriented toward the patient's left, in the 3 o'clock position </label> <label><<radiobutton "$echo3_quiz_placement" 5 autocheck>> Place the transducer in the subxiphoid window with the orientation mark toward the patient's head and slightly tilted to the patient's right </label> What do you think about the LV Ejection Fraction? <label><<radiobutton "$echo3_quiz_ef" 1 autocheck >> Reduced ejection fraction (<40%) </label> <label><<radiobutton "$echo3_quiz_ef" 2 autocheck >> Moderately reduced ejection fraction (40-49%) </label> <label><<radiobutton "$echo3_quiz_ef" 3 autocheck >> Preserved ejection fraction (≥50%) </label> Please answer all questions before continuing. <<repeat 0.2s>><<if ($echo3_quiz_view * $echo3_quiz_view_2 * $echo3_quiz_features * $echo3_quiz_ef * $echo3_quiz_placement)>> [[Continue|Case stare 3]] <<stop>><</if>><</repeat>> /* Reprimand and return to diagnostic evaluation. */

The consulting cardiologist tells you that you need a few more diagnostic steps before proceeding to treatment. <img style='width: 100%' src="https://images2.imgbox.com/1b/e7/hP0DDp29_o.jpeg"> <<set $diagnostics_3_reprimand += 1>> [[Continue|Case stare 3]]

The mitral valve showed thickened cusps with commissural fusion and reduced opening, compatible with mitral stenosis due to severe rheumatic heart disease. <img src="https://upload.wikimedia.org/wikipedia/commons/8/86/Severe_mitral_valve_stenosis%2C_mitral_regurgitation%2C_aortic_regurgitation_E00624_%28CardioNetworks_ECHOpedia%29.jpg"> <<silently>> <<set $diuretics_3 to false>> <<set $penicillin_3 to false>> <<set $beta_blocker_3 to false>> <<set $inotropes_3 to false>> <<set $fluids_3 to false>> <</silently>> Choose from the following options those that you think would be part of the appropriate treatment. <<checkbox "$diuretics_3" false true>> Diuretics /* Correct */ <<checkbox "$inotropes_3" false true>> Consult physician /* Correct */ <<checkbox "$penicillin_3" false true>> Refer to Uganda Heart Institute /* Correct */ <<checkbox "$beta_blocker_3" false true>> Give fluids /* Wrong */ <<checkbox "$fluids_3" false true>> Give Penicillin /* Correct */ [[Continue|Guideline treatment 3]]

<<silently>> <<if $diuretics_3>> <<set $case_3_Tx_score += 3>> <</if>> <<if $penicillin_3>> <<set $case_3_Tx_score += 2>> <</if>> <<if $beta_blocker_3>> <<set $case_3_Tx_score += 3>> <</if>> <<if $inotropes_3>> <<set $case_3_Tx_score -= 2>> <</if>> <<if $fluids_3>> <<set $case_3_Tx_score -= 3>> <</if>> <</silently>> <img src="https://www.radiocomnetu.org/mamafm/wp-content/uploads/sites/12/2024/08/image-from-rawpixel-id-3372984-jpeg-1024x683.jpg"> After consulting with the attending physician, Kasozi is started on diuretics, penicillin and is referred to the Uganda heart institute for further management. [[Continue|Mitral valve intervention 3]]

<img src="https://images2.imgbox.com/1b/e7/hP0DDp29_o.jpeg"> /* skipped here */ The MDS asks you what you believe should be the next step in managing this patient. [[Discharge Home on Oral Diuretics|Discharge home 3]] [[Keep in Hospital for Further Management|Mitral valve intervention 3]]

According to guidelines, the patient should remain in the hospital until a clear treatment plan is in place! <<set $case_3_Fu_score -= 3 >> [[Continue|Mitral valve intervention 3]]

Given the discovery of mitral stenosis, a consultation with a cardiologist should be arranged for possible intervention. <img src="https://images.rawpixel.com/image_800/cHJpdmF0ZS9sci9pbWFnZXMvd2Vic2l0ZS8yMDIyLTA1L2ZsMzA1MTU1NjE5MjgtaW1hZ2Uta3Bxb3AybHkuanBn.jpg"> <<set $case_3_Fu_score += 2 >> One month later, Kasozi comes for a follow-up visit to renew her medication prescriptions. She tells you that the swelling in her legs has improved significantly and that she sleeps better at night. She thanks you for your help! Congratulations! You have just completed the second case! The diagnostic approach to a suspected underlying heart disease should involve a thorough history and a complete physical examination, as the symptoms are generally non-specific (cough, dyspnea, fatigue). The cardiac echo can aid in diagnostic evaluation, showing left atrial dilation, pulmonary hypertension, and doming and restricted opening of the mitral valve. ''The appropriate treatment for this patient includes diuretics to manage pulmonary edema, penicillin to prevent recurrence of acute rheumatic fever, and beta-blockers.'' In general, evaluation and management by a cardiologist are strongly recommended in cases of mitral stenosis, as treatment guidelines tend to be complex. The next step in managing this patient is to refer her for mitral valve intervention, as severe mitral stenosis is a potentially life-threatening condition that requires urgent treatment. [[See the next patient|Case 2 introduction]]

<img src="https://images2.imgbox.com/1a/3c/Xddhg5NR_o.jpg"> Namatovu, a 34-year-old woman and mother of three children, presents to the hospital. She reports having a cough and several episodes of paroxysmal nocturnal dyspnea (“feeling of choking at night”) that started two weeks after giving birth to her third child. She tried taking some local herbs for the “lung infection” she had a few months ago, but the cough did not go away. Namatovu also mentions that about a month before her delivery, she started feeling weak and had to change her shoes because her feet wouldn’t fit anymore (“Feet got bigger”). She did not seek help at that time. On examination, she does not have a fever; her white cell count is 7,500/ml and her blood pressure is 90/60 mmHg. Her heart rate is 120 bpm. Based on her medical history, it’s clear she had no prior health problems. What is your first step in the management of this patient? [[Physical Exam|Physical Exam 4]] [[EKG|EKG 4]] [[Chest X-Ray|Chest X-Ray 4]] [[Labs|Labs 4]] [[Echo|Echo 4]] <<silently>> <<set $diagnostics_4_physical_exam to 0>> /* on main, verify sheet */ <<set $diagnostics_4_cxr to 0 >> <<set $diagnostics_4_labs to 0 >> <<set $diagnostics_4_echo_diagnosis to 0 >> /* on main, verify sheet */ <<set $diagnostics_4_premature_treatment to 0 >> /* on main, verify sheet */ <<set $case_4_Tx_score to 0>> /* on main, verify sheet */ <<set $case_4_Fu_score to 0>> /* on main, verify sheet */ <<set $case_4_Echo to 0>> /* on main, verify sheet */ <<set $echo4_quiz_view to 0>> /* on main, verify sheet */ <<set $echo4_quiz_placement to 0>> /* on main, verify sheet */ <<set $echo4_quiz_view_2 to 0>> /* on main, verify sheet */ <<set $echo4_quiz_view_3 to 0>> /* on main, verify sheet */ <<set $echo4_quiz_lvef to 0>> /* on main, verify sheet */ <<set $diuretics_4 to false>> /* on main, verify sheet */ <<set $antihypertensives_4 to false>> /* on main, verify sheet */ <<set $beta_blocker_4 to false>> /* on main, verify sheet */ <<set $albuterol_4 to false>> /* on main, verify sheet */ <<set $q_stop_beta_4 to false>> /* on main, verify sheet */ <<set $q_stop_ACE_4 to false>> /* on main, verify sheet */ <<set $p_stop_beta_4 to false>> /* on main, verify sheet */ <<set $p_stop_ACE_4 to false>> /* on main, verify sheet */ <<set $stop_beta_4 to false>> /* on main, verify sheet */ <<set $stop_ACE_4 to false>> /* on main, verify sheet */ <<set $b_stop_beta_4 to false>> /* on main, verify sheet */ <<set $b_stop_ACE_4 to false>> /* on main, verify sheet */ <<set $mortality_meds_4_arb to false>> /* on main, verify sheet */ <<set $mortality_meds_4_ccb to false>> /* on main, verify sheet */ <<set $mortality_meds_4_ace to false>> /* on main, verify sheet */ <<set $mortality_meds_4_bb to false>> /* on main, verify sheet */ <<set $mortality_meds_4_spiro to false>> /* on main, verify sheet */ <<set $q_stop_none_4 to false>> /* on main, verify sheet */ <<set $p_stop_none_4 to false>> /* on main, verify sheet */ <</silently>> /* Case stare is the intermediate step after each diagnosis choice, instead of showing the original case presentation. Plus, it shows only tests not already done yet and some notes for quick review. */

What is your next step? <img src="https://cdn12.picryl.com/photo/2016/12/31/doctors-office-doctor-office-health-medical-45c528-1024.jpg"> [[Physical Exam|Physical Exam 4]] [[EKG|EKG 4]] [[Chest X-Ray|Chest X-Ray 4]] [[Labs|Labs 4]] [[Echo|Echo 4]] <<if hasVisited("Labs 4", "Echo 4", "Physical Exam 4")>> [[Continue to Treatment|Treatment 4]] <<else>> [[Continue to Treatment|Not done Dx yet 4]] <</if>> /* Diagnostic choices start. */

You begin a physical exam on Namatovu. <<set $diagnostics_4_physical_exam to 1>> You notice distended neck veins and swelling of her feet. She says her “belly is heavy, like she's still pregnant.” Her abdomen appears distended, and on palpation, you can clearly appreciate free fluid (ascites). On lung auscultation, you hear crackles. [[Continue| Case stare 4]]

Some time later, the nurse hands you the following chest X-ray: <img style='width: 100%' src="https://prod-images-static.radiopaedia.org/multiple_choice_questions/420/bat-wings-pulmonary-oedema_big_gallery.jpeg"> <<set $diagnostics_4_cxr to 1>> [[Read the radiologist report|Radiologist 4]] [[Continue| Case stare 4]]

The admission chest radiograph showed acute pulmonary edema with bilateral pleural effusions and cardiomegaly. [[Continue|Case stare 4]]

<<set $diagnostics_4_labs to 1>> In the emergency department, blood was drawn and sent to the lab. A few hours later, the following lab results come back: White blood cell count: 6.7 k/ml Hb: 9.8 g/dL Creatinine: 2.1 mg/dL NT pro-BNP: 956 pg/mL **HIGH** (upper normal limit 125 pg/mL) [[Continue|Case stare 4]]

/* Diffuse T wave inversion. */ Here is the EKG. <img style='width: 100%' src="https://www.aafp.org/content/dam/brand/aafp/pubs/afp/issues/2014/0815/p257-uf1.jpg"> [[Continue|Case stare 4]]

The cardiac echo is shown below: <img style='width: 100%' src="https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1680198032131-P2FIQDODZHSKVCF9JZKP/image-asset.gif?format=500w"> Which echographic view is this? /* Parasternal long */ <label><<radiobutton "$echo4_quiz_view" 1 autocheck >> Parasternal long axis </label> <label><<radiobutton "$echo4_quiz_view" 2 autocheck >> Parasternal short axis </label> <label><<radiobutton "$echo4_quiz_view" 3 autocheck >> Apical 4-chamber</label> <label><<radiobutton "$echo4_quiz_view" 4 autocheck >> Apical 2-chamber</label> <label><<radiobutton "$echo4_quiz_view" 5 autocheck >> Subxiphoid </label> How is this echographic view obtained? <label><<radiobutton "$echo4_quiz_placement" 1 autocheck>> Place the transducer in the parasternal window with the transducer index mark oriented toward the patient's right shoulder (10 o'clock) in the third or fourth intercostal space. </label> <label><<radiobutton "$echo4_quiz_placement" 2 autocheck>> Place the transducer in the left parasternal fourth or fifth intercostal space in a line connecting the left clavicle/shoulder and the right hip, with the transducer rotated 90 degrees clockwise relative to the parasternal long-axis view. </label> <label><<radiobutton "$echo4_quiz_placement" 3 autocheck>> Place the transducer at the point of maximal impulse with the indicator pointing to the patient’s left side. </label> <label><<radiobutton "$echo4_quiz_placement" 4 autocheck>> Place the transducer on the patient’s abdomen in the subcostal region, slightly to the right of midline. The index mark is oriented to the patient’s left (3 o’clock). </label> <label><<radiobutton "$echo4_quiz_placement" 5 autocheck>> Place the transducer in the subxiphoid window with the orientation mark toward the patient’s head and slightly tilted toward the patient’s right. </label> <img style='width: 100%' src="https://images2.imgbox.com/53/1d/nzetW9Pm_o.gif"> Which echographic view is this? <label><<radiobutton "$echo4_quiz_view_2" 1 autocheck >> Parasternal long axis </label> <label><<radiobutton "$echo4_quiz_view_2" 2 autocheck >> Parasternal short axis </label> <label><<radiobutton "$echo4_quiz_view_2" 3 autocheck >> Apical 4-chamber</label> <label><<radiobutton "$echo4_quiz_view_2" 4 autocheck >> Apical 2-chamber </label> <label><<radiobutton "$echo4_quiz_view_2" 5 autocheck >> Subxiphoid </label> <img style='width: 100%' src="https://images2.imgbox.com/d2/6b/vsyzkPcu_o.jpg"> Which echographic view is this? /* Correct is subxiphoid */ <label><<radiobutton "$echo4_quiz_view_3" 1 autocheck >> Parasternal long axis </label> <label><<radiobutton "$echo4_quiz_view_3" 2 autocheck >> Parasternal short axis </label> <label><<radiobutton "$echo4_quiz_view_3" 3 autocheck >> Apical 4-chamber </label> <label><<radiobutton "$echo4_quiz_view_3" 4 autocheck >> Apical 2-chamber </label> <label><<radiobutton "$echo4_quiz_view_3" 5 autocheck >> Subxiphoid </label> What do you think of the LV ejection fraction? /* Correct is <40% */ <label><<radiobutton "$echo4_quiz_lvef" 1 autocheck >> Reduced ejection fraction (<40%) </label> <label><<radiobutton "$echo4_quiz_lvef" 2 autocheck >> Mid-range ejection fraction (40-49%) </label> <label><<radiobutton "$echo4_quiz_lvef" 3 autocheck >> Preserved ejection fraction (≥50%) </label> What do you think these echo images show? /* Correct is dilated left ventricle, low ejection fraction, dilated IVC */ <label><<radiobutton "$diagnostics_4_echo_diagnosis" 1 autocheck>> Large pericardial effusion and evidence of tamponade </label> <label><<radiobutton "$diagnostics_4_echo_diagnosis" 2 autocheck>> Dilated left ventricle, low ejection fraction, dilated IVC </label> <label><<radiobutton "$diagnostics_4_echo_diagnosis" 3 autocheck>> Bicuspid aortic valve, aortic stenosis </label> Please answer all questions before continuing. <<repeat 0.2s>><<if ($echo4_quiz_view * $echo4_quiz_view_2 * $echo4_quiz_view_3 * $echo4_quiz_lvef * $echo4_quiz_placement * $diagnostics_4_echo_diagnosis)>> [[Continue|Case stare 4]]<<stop>><</if>><</repeat>> /* Reprimand and return to diagnostic evaluation. */

The consulting cardiologist thinks you need a few more diagnostic steps before moving on to treatment. <img src="https://images.pexels.com/photos/5327647/pexels-photo-5327647.jpeg"> <<set $diagnostics_4_premature_treatment += 1>> [[Continue|Case stare 4]]

The echocardiogram showed severely reduced left ventricular systolic function with a low ejection fraction of 30% and a dilated inferior vena cava. Both ventricles appear dilated and biatrial enlargement was also noted. <img src="https://upload.wikimedia.org/wikipedia/commons/d/da/2D_ECHOCARDIOGRAM_MACHINE_WITH_A_TABLE_AND_A_STETHOSCOPE.jpg"> Remember that the cardiac echo and the NT pro-BNP are necessary to perform for diagnosing this patient. Among the following medications, choose those that you believe would be part of appropriate management. <<checkbox "$diuretics_4" false true>> IV Furosemide <<checkbox "$albuterol_4" false true>> Inhaled Albuterol <<checkbox "$antihypertensives_4" false true>> Antihypertensives <<checkbox "$beta_blocker_4" false true>> Beta-blocker [[Continue|Treatment Result 4]]

<<if $diuretics_4 >> Furosemide was the correct choice of treatment! The goal of treatment for this patient with peripartum cardiomyopathy is to control heart failure symptoms. In the acute setting, diuresis is the cornerstone of treatment. Furosemide or bumetanide can be used for pulmonary edema, but overdiuresing carries a risk of placental hypoperfusion and fetal electrolyte abnormalities if the patient is pregnant. <<else>> Treatment with diuretics would be the appropriate treatment for this patient. The goal of treatment for this patient with peripartum cardiomyopathy is to control heart failure symptoms. In the acute setting, diuresis is the cornerstone of treatment. Furosemide or bumetanide can be used for pulmonary edema, but overdiuresing carries a risk of placental hypoperfusion and fetal electrolyte abnormalities if the patient is pregnant. <</if>> <<silently>> <<if $diuretics_4>> <<set $case_4_Tx_score += 2>> <</if>> <<if $antihypertensives_4>> <<set $case_4_Tx_score -= 4>> <</if>> <<if $beta_blocker_4>> <<set $case_4_Tx_score -= 2>> <</if>> <<if $albuterol_4>> <<set $case_4_Tx_score -= 4>> <</if>> <</silently>> Despite your best efforts, the patient deteriorates.The next day, a colleague calls you because Namatovu complains of worsening shortness of breath. She also notes that the patient has had minimal urine output and very low blood pressure. You go to Namatovu’s room to check on her and see she has produced about 309 ml of urine in the last 24 hours. She is clearly in distress, breathing rapidly, and the pulse oximeter reads 87%. What is your next step? <label><<radiobutton "$deterioration_4" 1 autocheck >> Consult cardiologist </label> <label><<radiobutton "$deterioration_4" 0 autocheck >> Continue managing patient with escalated medication regimen </label> [[Continue|Improvement 4]]

Namatovu’s labs after ICU admission show: Lactate = 5.4 mg/dL, ALT = 123 mg/dL, AST = 140 mg/dL. Her thyroid function tests came back normal. In your opinion, what is the best medical therapy? [[Oxygen and inotropes|Incorrect ICU mgmt 4]] [[High-dose IV diuretics|Incorrect ICU mgmt 4]] [[Oxygen alone|Incorrect ICU mgmt 4]] [[Oxygen, inotropes, high-dose diuretics|Improvement 4]]

Before initiating therapy, after consulting your attending physician, you decide to include everything in your treatment plan: oxygen, inotropes, and high-dose diuretics. [[Continue|Improvement 4]]

Namatovu’s condition has significantly improved. On physical examination, there are no crackles in her lungs, the swelling in her legs has resolved, and her abdominal distension has decreased. She reports feeling much better and is able to sleep comfortably at night without episodes of dyspnea. Her BNP levels have decreased, indicating a positive response to treatment. Continued monitoring of her symptoms, BNP levels, and echocardiographic findings will be important to guide further management. Guideline-Directed Medical Therapy (GDMT): Medications such as ACE inhibitors (e.g., lisinopril), ARBs (e.g., losartan), or beta-blockers (e.g., metoprolol) are essential for improving morbidity and mortality in heart failure patients. Diuretics, while not shown to improve long-term outcomes, are crucial for symptom management and patient comfort. [[Continue|Further management 4]]

Which of the following medications have been found to prolong mortality and morbidity in heart failure patients? Choose all that apply. <<checkbox "$mortality_meds_4_arb" false true>> Losartan (ARB) <<checkbox "$mortality_meds_4_ccb" false true>> Amlodipine (calcium Channel Blockers) <<checkbox "$mortality_meds_4_ace" false true>> Lisinopril (ACE-Inhibitor) <<checkbox "$mortality_meds_4_bb" false true>> Metoprolol (Beta-Blocker) <<checkbox "$mortality_meds_4_spiro" false true>> Spironolactone (K+ sparing diuretics) <img src="https://pix4free.org/assets/library/2021-10-07/originals/heart-disease.jpg"> [[Continue|Case conclusion 4]]

The repeat echo is shown below: <img style='width: 100%' src="https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1533340755751-28DSIIEOY3LCLELVB8FQ/parasternal+long+axis+normal.gif?format=500w"> <img style='width: 100%' src="https://images.squarespace-cdn.com/content/v1/58118909e3df282037abfad7/1515544100377-BDN6UHGVSAYQOGJO3PT8/ezgif.com-optimize+%286%29.gif?format=500w "> [[Continue|Patient Questions 4]]

<img src="https://images.pexels.com/photos/161688/medical-tablets-pills-drug-161688.jpeg"> Namatovu returns for her follow-up appointment. She is very happy about her improvement and has a few questions: “It’s been a while since I was in the hospital, and I can now sleep normally at night ever since I got here. Also, as far as I know, the echo results look normal. Do I need to keep taking all these pills?” Please choose the correct response (assuming you have the pill bottles in front of you and can directly show the patient which pills she needs to keep taking): <<checkbox "$stop_beta_4" false true>> “Since you feel fine, you can stop taking the beta-blocker, but you must continue the ACEi/ARB.” <<checkbox "$stop_ACE_4" false true>> “Since you feel fine, you can stop taking the ACEi/ARB, but you must continue the beta-blocker.” None of these: “You must continue taking both medications to maintain your improvement.” Which medications are safe to take during breastfeeding? Namatovu nods in understanding but seems skeptical. She then asks: “Are you sure my baby is safe? I’m worried that these medications might affect my baby since I’m exclusively breastfeeding.” <<checkbox "$b_stop_beta_4" false true>> “In that case, since you’re breastfeeding, you must stop taking the beta-blocker.” <<checkbox "$b_stop_ACE_4" false true>> “In that case, since you’re breastfeeding, you must stop taking the ACEi/ARB.” [[Continue|Attending questions 4]]

/* Evaluate answers to patient questions */ <<silently>> <<if $stop_beta_4>> <<set $case_4_Fu_score -= 2>> <</if>> <<if $stop_ACE_4>> <<set $case_4_Fu_score -= 2>> <</if>> <<if $b_stop_beta_4>> <<set $case_4_Fu_score -= 2>> <</if>> <<if $b_stop_ACE_4>> <<set $case_4_Fu_score -= 2>> <</if>> <</silently>> <img src="https://images.rawpixel.com/image_800/cHJpdmF0ZS9sci9pbWFnZXMvd2Vic2l0ZS8yMDIyLTExL2ZsNTE3MTMzNzczMDMtaW1hZ2UuanBn.jpg"> The attending physician also tests your knowledge: “Let’s say this patient complains of symptoms indicating hypotensive episodes. What would you suggest?” <<checkbox "$q_stop_beta_4" false true>> She should stop taking the beta-blocker. <<checkbox "$q_stop_ACE_4" false true>> She should stop taking the ACEi/ARB. Leave blank if she should continue both medications. <<checkbox "$p_stop_beta_4" false true>> She should stop taking the beta-blocker. <<checkbox "$p_stop_ACE_4" false true>> She should stop taking the ACEi/ARB. Leave blank if she should continue both medications. /*If the attending questions are used, put these in the next passage.*/ /% Evaluate answers to the attending physician. %/ <<silently>> <<if $q_stop_beta_4>> <<set $case_4_Fu_score -= 2>> <</if>> <<if $q_stop_ACE_4>> <<set $case_4_Fu_score += 2>> <</if>> <<if !$p_stop_beta_4 && !$p_stop_ACE_4>> <<set $case_4_Fu_score -= 4>> <<set $p_stop_none_4 to true>> <</if>> <<if $p_stop_beta_4>> <<set $case_4_Fu_score -= 2>> <</if>> <<if $p_stop_ACE_4>> <<set $case_4_Fu_score += 4>> <</if>> <<if !$q_stop_beta_4 && !$q_stop_ACE_4>> <<set $case_4_Fu_score -= 4>> <<set $q_stop_none_4 to true>>  <</if>> <</silently>> [[Continue|Case conclusion 4]]

Namatovu thanks you for your help and promises that at the next appointment, she’ll bring you a photo of her son! She says she’s very happy she can sleep well at night with the new medications! Congratulations! You’ve completed Case 1! <img src="https://images2.imgbox.com/0d/0d/rz4AaRuD_o.jpg"> ''Key Takeaways:'' !!! Peripartum Cardiomyopathy (PPCM): * ''Suspect PPCM'' in postpartum patients with heart failure symptoms (e.g., dyspnea, edema, fatigue). * ''Diagnosis:'' * Echocardiography is critical to confirm reduced LV ejection fraction (<45%), * Ventricular dilation, and * Exclusion of other causes. !!! Medications in PPCM: ''Acute Management:'' * Diuretics (e.g., furosemide) for pulmonary edema. * Inotropes (e.g., dobutamine) for cardiogenic shock. ''Long-Term Therapy:'' * Beta-blockers (e.g., metoprolol): Improve survival and LV function. * ACE inhibitors (e.g., enalapril, captopril) or ARBs: Start postpartum (safe in breastfeeding). * Sacubitril/valsartan: Consider in stable patients if ACEi/ARB is insufficient. * Spironolactone: For persistent symptoms (avoid in pregnancy). !!! Safety in Pregnancy/Breastfeeding: ''Pregnancy:'' * Contraindicated: ACE inhibitors, ARBs, spironolactone, ARNIs. * Alternatives: Hydralazine + ISDN for afterload reduction. ''Breastfeeding:'' * Safe: Enalapril, captopril, benazepril (ACEi); metoprolol (beta-blocker). * Avoid: Lisinopril, ARBs (e.g., losartan). !!! Adjunctive Therapies: * Thromboprophylaxis: LMWH or warfarin (if LVEF <35%) due to high thromboembolism risk. * Iron Supplementation: If anemia is present (common in PPCM). !!! Monitoring: * Serial echocardiograms and BNP levels to track recovery. !!! Patient Counseling: * ''Do NOT'' stop medications (beta-blockers/ACEi) even if symptoms resolve — sudden discontinuation risks relapse. * Future pregnancies require careful preconception counseling (high recurrence risk). You can review guidelines on cardiovascular medications for pregnant, postpartum, and breastfeeding patients here: [[Cardiovascular disease medication during pregnancy|https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2019/01/28/18/53/use-of-medication-for-cvd-during-pregnancy]] [[Continue|Case 3 introduction]]

<<set $history to []>> <<set $started to 0>> <<set $wrong_password to false>> <<set $case_1_dx_score to 0>> <<set $case_1_Tx_score to 0>> <<set $submitted to 0>> <<set $history to []>> <<set $started to 0>> <<set $wrong_password to false>> <<set $submitted to 0>> <<set $id to "thats_good">> /* Case 1 Variables */ <<set $physical_exam_1 to 0>> <<set $EKG_1 to 0>> <<set $CXR_1 to 0>> <<set $Labs_1 to 0>> <<set $reprimand_1 to 0>> <<set $case_1_dx_score to 0>> <<set $case_1_Tx_score to 0>> <<set $case_1_Fu_score to 0>> <<set $case_1_Echo to 0>> <<set $echo1_quiz to [0,0,0,0,0]>> /* Case 2 Variables */ <<set $diagnostics_2 to [0,0,0,0,0,0]>> <<set $case_2_Tx_score to 0>> <<set $case_2_Fu_score to 0>> <<set $case_2_fundoscopy to 0>> <<set $case_2_orthostatics to 0>> <<set $case_2_dix_hallpike to 0>> <<set $case_2_kernig_brudzinsky to 0>> <<set $ddx_2_HTeCM to "">> <<set $echo2_quiz to [0,0,0,0,0]>> /* Case 3 Variables */ <<set $diagnostics_3 to [0,0,0,0,0,0]>> <<set $case_3_Tx_score to 0>> <<set $case_3_Fu_score to 0>> <<set $echo3_quiz to [0,0,0,0,0]>> /* Case 4 Variables */ <<set $diagnostics_4_physical_exam to 0>> <<set $diagnostics_4_cxr to 0 >> <<set $diagnostics_4_labs to 0 >> <<set $diagnostics_4_echo_diagnosis to 0 >> <<set $diagnostics_4_premature_treatment to 0 >> <<set $case_4_Tx_score to 0>> <<set $case_4_Fu_score to 0>> <<set $case_4_Echo to 0>> <<set $echo4_quiz_view to 0>> <<set $echo4_quiz_placement to 0>> <<set $echo4_quiz_view_2 to 0>> <<set $echo4_quiz_view_3 to 0>> <<set $echo4_quiz_lvef to 0>> <<set $diuretics_4 to false>> <<set $antihypertensives_4 to false>> <<set $beta_blocker_4 to false>> <<set $albuterol_4 to false>> <<set $q_stop_beta_4 to false>> <<set $q_stop_ACE_4 to false>> <<set $p_stop_beta_4 to false>> <<set $p_stop_ACE_4 to false>> <<set $stop_beta_4 to false>> <<set $stop_ACE_4 to false>> <<set $b_stop_beta_4 to false>> <<set $b_stop_ACE_4 to false>> /* Usability Survey */ <<set $usability to [0,0,0,0,0,0,0,0,0,0]>>

/* Note: time is measured in milliseconds since Unix Epoch. (January 1, 1970 00:00:00 UTC) */ /* Update the time of the previous history record if there is one. */ <<if $history.length gt 0>> <<set $history.last().time to Date.now()>> <<else>> /* Record the time the first passage was shown. */ <<set $started to Date.now()>> <</if>> /* Add current passage's history record to the array, unless it has a 'no-history' passage tag. */ <<if not tags().includes('no-history')>> <<set $history.push({ "passage": passage(), "time": 0 })>> <</if>>

<<silently>> <<set _answer to "">> <<set $has_access = 0>> <<if $wrong_password>> Wrong password! <</if>> <</silently>> Please enter your trainee ID to continue. <<textbox "_answer" "">> <<button "Verify password">> <<if _answer is "">> /% They have not supplied an answer. %/ <<script>>UI.alert("You haven't provided a password!");<</script>> <<else>> /% Remove extra white space from both ends of the answer then convert it to lowercase. %/ <<set _answer to _answer.trim().toLowerCase()>> /% Check if one of the correct answers was supplied, otherwise send them back to the Start passage. %/ <<switch _answer>> <<case "password">> <<set $has_access = 1>> <<case "password2">> <<set $has_access = 1>> <<default>> <<set $has_access = 0>> <</switch>> <<if $has_access>> <<set $id = _answer>> <<goto "Waiting Room">> /* Waiting Room */ <<else>> /% Send the reader back to the start. %/ <<set $wrong_password to true>> <<goto "Guard">> <</if>> <</if>> <</button>>

Global MedEd Network FoCUS-Uganda 2025 For an optimal platform experience, please use Chrome. You will need an audio source to complete this activity. Welcome to gmenecho! This is a virtual learning tool for clinicians that helps us evaluate the effectiveness of the training program you are participating in. You will work on four clinical cases. Once you’ve completed them, you’ll fill out a program evaluation form before taking the exam. Please begin when you are ready. This should take about half an hour. [[Start the first case|Case 4 introduction]]

<<set $usability to [0, 0, 0, 0, 0, 0, 0, 0, 0, 0]>> A. I think I would like to use this learning tool frequently. Please choose from the following options: <label><<radiobutton "$usability[0]" 1 autocheck>> 1 Strongly disagree </label> <label><<radiobutton "$usability[0]" 2 autocheck>> 2 Disagree </label> <label><<radiobutton "$usability[0]" 3 autocheck>> 3 Neutral </label> <label><<radiobutton "$usability[0]" 4 autocheck>> 4 Agree </label> <label><<radiobutton "$usability[0]" 5 autocheck>> 5 Strongly agree</label> B. I found the learning tool useless and complex. Please choose from the following options: <label><<radiobutton "$usability[1]" 1 autocheck>> 1 Strongly disagree </label> <label><<radiobutton "$usability[1]" 2 autocheck>> 2 Disagree </label> <label><<radiobutton "$usability[1]" 3 autocheck>> 3 Neutral </label> <label><<radiobutton "$usability[1]" 4 autocheck>> 4 Agree </label> <label><<radiobutton "$usability[1]" 5 autocheck>> 5 Strongly agree</label> C. I thought the learning tool was easy to use. Please choose from the following options: <label><<radiobutton "$usability[2]" 1 autocheck>> 1 Strongly disagree </label> <label><<radiobutton "$usability[2]" 2 autocheck>> 2 Disagree </label> <label><<radiobutton "$usability[2]" 3 autocheck>> 3 Neutral </label> <label><<radiobutton "$usability[2]" 4 autocheck>> 4 Agree </label> <label><<radiobutton "$usability[2]" 5 autocheck>> 5 Strongly agree</label> D. I think I would need technical support to be able to use this learning tool. Please choose from the following options: <label><<radiobutton "$usability[3]" 1 autocheck>> 1 Strongly disagree </label> <label><<radiobutton "$usability[3]" 2 autocheck>> 2 Disagree </label> <label><<radiobutton "$usability[3]" 3 autocheck>> 3 Neutral </label> <label><<radiobutton "$usability[3]" 4 autocheck>> 4 Agree </label> <label><<radiobutton "$usability[3]" 5 autocheck>> 5 Strongly agree</label> E. I found the various functions in this learning tool were well integrated. Please choose from the following options: <label><<radiobutton "$usability[4]" 1 autocheck>> 1 Strongly disagree </label> <label><<radiobutton "$usability[4]" 2 autocheck>> 2 Disagree </label> <label><<radiobutton "$usability[4]" 3 autocheck>> 3 Neutral </label> <label><<radiobutton "$usability[4]" 4 autocheck>> 4 Agree </label> <label><<radiobutton "$usability[4]" 5 autocheck>> 5 Strongly agree</label> F. I thought there was too much inconsistency in this learning tool. Please choose from the following options: <label><<radiobutton "$usability[5]" 1 autocheck>> 1 Strongly disagree </label> <label><<radiobutton "$usability[5]" 2 autocheck>> 2 Disagree </label> <label><<radiobutton "$usability[5]" 3 autocheck>> 3 Neutral </label> <label><<radiobutton "$usability[5]" 4 autocheck>> 4 Agree </label> <label><<radiobutton "$usability[5]" 5 autocheck>> 5 Strongly agree</label> G. I imagine that most people would learn to use this learning tool very quickly. Please choose from the following options: <label><<radiobutton "$usability[6]" 1 autocheck>> 1 Strongly disagree </label> <label><<radiobutton "$usability[6]" 2 autocheck>> 2 Disagree </label> <label><<radiobutton "$usability[6]" 3 autocheck>> 3 Neutral </label> <label><<radiobutton "$usability[6]" 4 autocheck>> 4 Agree </label> <label><<radiobutton "$usability[6]" 5 autocheck>> 5 Strongly agree</label> H. I found the learning tool very cumbersome to use. Please choose from the following options: <label><<radiobutton "$usability[7]" 1 autocheck>> 1 Strongly disagree </label> <label><<radiobutton "$usability[7]" 2 autocheck>> 2 Disagree </label> <label><<radiobutton "$usability[7]" 3 autocheck>> 3 Neutral </label> <label><<radiobutton "$usability[7]" 4 autocheck>> 4 Agree </label> <label><<radiobutton "$usability[7]" 5 autocheck>> 5 Strongly agree</label> I. I felt very comfortable using the learning tool. Please choose from the following options: <label><<radiobutton "$usability[8]" 1 autocheck>> 1 Strongly disagree </label> <label><<radiobutton "$usability[8]" 2 autocheck>> 2 Disagree </label> <label><<radiobutton "$usability[8]" 3 autocheck>> 3 Neutral </label> <label><<radiobutton "$usability[8]" 4 autocheck>> 4 Agree </label> <label><<radiobutton "$usability[8]" 5 autocheck>> 5 Strongly agree</label> J. I had to learn a lot of things before I could use this learning tool. Please choose from the following options: <label><<radiobutton "$usability[9]" 1 autocheck>> 1 Strongly disagree </label> <label><<radiobutton "$usability[9]" 2 autocheck>> 2 Disagree </label> <label><<radiobutton "$usability[9]" 3 autocheck>> 3 Neutral </label> <label><<radiobutton "$usability[9]" 4 autocheck>> 4 Agree </label> <label><<radiobutton "$usability[9]" 5 autocheck>> 5 Strongly agree</label> Please answer all questions before continuing. <<repeat 0.2s>><<if ($usability[0] * $usability[1] * $usability[2] * $usability[3] * $usability[4] * $usability[5] * $usability[6] * $usability[7] * $usability[8] * $usability[9])>> [[Continue|Score report]]<<stop>><</if>><</repeat>>

<<script src="https://code.jquery.com/jquery-3.3.1.min.js">><</script>> Please submit your results, then restart if someone else wants to use the same device. Thank you! <div id="first"> <<script>> // First calculate time durations for each passage let passageTimes = {}; let lastTime = State.variables.started; const passageHistoryWithDuration = State.variables.history.map((event, index) => { if (event.time) { const duration = (event.time - lastTime) / 1000; // Convert to seconds lastTime = event.time; return { passage: event.passage, time: event.time / 1000, // Convert to seconds duration: duration }; } else { return { passage: event.passage, time: 0, duration: 0 }; } }); // Prepare the complete data object const sendData = JSON.stringify({ "ID": State.variables.id, "diagnostics_4_physical_exam": State.variables.diagnostics_4_physical_exam, "diagnostics_4_echo_diagnosis": State.variables.diagnostics_4_echo_diagnosis, "diagnostics_4_premature_treatment": State.variables.diagnostics_4_premature_treatment, "case_4_Tx_score": State.variables.case_4_Tx_score, "case_4_Fu_score": State.variables.case_4_Fu_score, "case_4_Echo": State.variables.case_4_Echo, "echo4_quiz_view": State.variables.echo4_quiz_view, "echo4_quiz_placement": State.variables.echo4_quiz_placement, "echo4_quiz_view_2": State.variables.echo4_quiz_view_2, "echo4_quiz_view_3": State.variables.echo4_quiz_view_3, "echo4_quiz_lvef": State.variables.echo4_quiz_lvef, "diuretics_4": State.variables.diuretics_4, "antihypertensives_4": State.variables.antihypertensives_4, "beta_blocker_4": State.variables.beta_blocker_4, "albuterol_4": State.variables.albuterol_4, "q_stop_beta_4": State.variables.q_stop_beta_4, "q_stop_ACE_4": State.variables.q_stop_ACE_4, "p_stop_beta_4": State.variables.p_stop_beta_4, "p_stop_ACE_4": State.variables.p_stop_ACE_4, "stop_beta_4": State.variables.stop_beta_4, "stop_ACE_4": State.variables.stop_ACE_4, "b_stop_beta_4": State.variables.b_stop_beta_4, "b_stop_ACE_4": State.variables.b_stop_ACE_4, "mortality_meds_4_arb": State.variables.mortality_meds_4_arb, "mortality_meds_4_ccb": State.varialbes.mortality_meds_4_ccb, "mortality_meds_4_ace": State.variables.mortality_meds_4_ace, "mortality_meds_4_bb": State.variables.mortality_meds_4_bb, "mortality_meds_4_spiro": State.variables.mortality_meds_4_spiro, "q_stop_none_4": State.variables.q_stop_none_4, "p_stop_none_4": State.variables.p_stop_none_4, "case_3_Tx_score": State.variables.case_3_Tx_score, "case_3_Fu_score": State.variables.case_3_Fu_score, "labs_most_suggestive_3": State.variables.labs_most_suggestive_3, "echo3_quiz_view": State.variables.echo3_quiz_view, "echo3_quiz_view_2": State.variables.echo3_quiz_view_2, "echo3_quiz_features": State.variables.echo3_quiz_features, "echo3_quiz_ef": State.variables.echo3_quiz_ef, "echo3_quiz_placement": State.variables.echo3_quiz_placement, "diagnostics_3_physical_exam": State.variables.diagnostics_3_physical_exam, "diagnostics_3_CXR": State.variables.diagnostics_3_CXR, "diagnostics_3_labs": State.variables.diagnostics_3_labs, "diagnostics_3_ekg: State.variables.diagnostics_3_ekg, "diagnostics_3_reprimand": State.variables.diagnostics_3_reprimand, "diuretics_3": State.variables.diuretics_3, "penicillin_3": State.variables.penicillin_3, "beta_blocker_3": State.variables.beta_blocker_3, "inotropes_3": State.variables.inotropes_3, "fluids_3": State.variables.fluids_3, "case_2_Tx_score": State.variables.case_2_Tx_score, "case_2_Fu_score": State.variables.case_2_Fu_score, "echo2_quiz_view": State.variables.echo2_quiz_view, "echo2_quiz_view_2": State.variables.echo2_quiz_view_2, "echo2_quiz_view_3": State.variables.echo2_quiz_view_3, "echo2_quiz_ef": State.variables.echo2_quiz_ef, "echo2_quiz_placement": State.variables.echo2_quiz_placement, "diagnostics_2_physical_exam": State.variables.diagnostics_2_physical_exam, "diagnostics_2_cxr": State.variables.diagnostics_2_cxr, "diagnostics_2_lab": State.variables.diagnostics_2_lab, "diagnostics_2_ekg": State.variables.diagnostics_2_ekg, "diagnostics_2_echo_impression": State.variables.diagnostics_2_echo_impression, "diagnostics_2_reprimand": State.variables.diagnostics_2_reprimand, "ddx_2_opinion": State.variables.ddx_2_opinion, "ddx_2_HTeCM": State.variables.ddx_2_HTeCM, "ddx_2_PICM": State.variables.ddx_2_PICM, "ddx_2_AST": State.variables.ddx_2_AST, "ddx_2_SAP": State.variables.ddx_2_SAP, "ddx_2_HTrCM": State.variables.ddx_2_HTrCM, "ddx_2_score": State.variables.ddx_2_score, "biggest_risk_2_htn": State.variables.biggest_risk_2_htn, "biggest_risk_2_obes": State.variables.biggest_risk_2_obes, "biggest_risk_2_diab": State.variables.biggest_risk_2_diab, "biggest_risk_2_occ": State.variables.biggest_risk_2_occ, "bp_control_2": State.variables.bp_control_2, "diuretics_2": State.variables.diuretics_2, "arbs_2": State.variables.arbs_2, "sglt_2": State.variables.sglt_2, "ace_arb_2": State.variables.ace_arb_2, "weight_control_2": State.variables.weight_control_2, "passage_history": JSON.stringify(passageHistoryWithDuration) }); 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