Mr Jack Smith is a 67-year-old male who lives with his wife, Deirdre, in a semi-detached house. He has been quite stressed for about a year now due to his two children both going through difficult divorces. For the past few months he has been experiencing a pounding in his chest and a feeling of breathlessness, both of which get worse after going up the stairs to the bedroom. He found that he had to rest on the landing for a few minutes to catch his breath after each ascent and felt lightheaded. Deirdre became concerned after Jack nearly fainted one morning, and she took him to the hospital the next day for a check-up, even though he thought it was probably nothing.

On arrival, the doctors ran an ECG and took blood and urine samples. Serum creatinine was found to be raised, and the urine was low in volume and very dark. Troponin levels and liver function were normal.

On examination, Jack had a raised BMI and capillary refill time was >5 seconds. His mouth and mucus membranes were very dry, and his legs were slightly swollen. His blood pressure was 80/50.

On auscultation, heart sounds: I + II + 0 and there were fine crackles at the base of each lung.

The doctors decided to put Jack on Warfarin and drugs for heart rate and rhythm control, gave him plenty of fluids, and kept him in hospital for monitoring. Jack began to feel better.

However, 3 days later in the morning while he was reaching for a glass of water by his bed, he realised that he couldn’t move his right arm properly and knocked the glass over onto the floor. He also experienced tingling and numbness in that hand, as well as tunnel vision. He felt as though he was drunk, even though he had not had any alcohol recently. The doctors were alerted immediately, and Jack was taken for a CT scan of his head.

After treatment for thrombolysis and several weeks of physiotherapy, Jack was able to return home with Deirdre, albeit with several more medications that he had to take.


You must:

  • Revise the gross anatomy of the heart from your A level textbooks
  • Research any terms in the case that you haven’t come across before
  • Research what a stroke is and how it occurs and presents


  1. What is the structure of a medical history?
  2. Discuss the positives and negatives of a CT scan. Why was it used in this case?
  3. What are the impacts of chronic stress on health and wellbeing?
  4. How do you clinically assess someone for dehydration?
  5. What is meant by a reference range?
  6. What condition are the doctors hoping to rule out by checking Jack’s troponin levels?
  7. What are the two types of stroke and how do the treatments differ?

You should:

  • Revise the electrical conduction system of the heart from your A level course.
  • Research what the normal ECG waveform looks like and link this to atrial and ventricular contraction and relaxation.
  • Research some common arrhythmias and pathologies that show up on the ECG trace.


  1. Why might someone not present to hospital with symptoms? What types of health behaviours is Jack showing in delaying seeking treatment?
  2. What type of arrhythmia does the ECG show?
  3. What complications can this condition cause?
  4. What is the Jack’s range in heart rate on the ECG trace?
  5. What does serum creatinine help diagnose?

You could:

  • Research the causes of breathlessness on exertion. Which of these have you heard of before?
  • Research causes of different heart sounds and pulmonary crackles.


  1. What is likely to have caused Jack’s bi-basal crackles?
  2. Are there any other things that can cause a rise in serum troponin?
  3. Suggest why Jack’s liver function has been checked and why his serum creatinine is raised.
  4. What is likely to have caused Jack’s dehydration?
  5. Summarise what you think has happened to Jack and suggest how his chronic condition has caused acute problems to develop.

We encourage students to research and post answers in the comments below and Medical Student Scholar Chris Geddie, will be answering your questions and reviewing your answers in a live discussion on the upcoming Virtual Medical Society Meeting on the 19th May.