Question

T.J. presented to the ER late one evening complaining of a "racing heartbeat". She is an overweight, 69 year old white female, who has been experiencing increasing shortness of breath during the past 2 months and marked swelling of her ankles and feet during the past 3 weeks. She feels very weak and tired most of the time and has recently been waking up in the middle of the night with severe breathing problems. She has been sleeping with several pillows to keep herself propped up.

Five years ago she suffered a transmural (through the entire thickness of the ventricular wall) anterior wall (left ventricle) myocardial infarction (MI). She received 2 vessel coronary artery bypass surgery 4 1/2 years ago for obstructions in the left anterior descending and left circumflex coronary arteries.

Her family history is positive for atherosclerosis as her father died from a heart attack and her mother had several CVAs (cerebral vascular accidents). She had been a 3 pack a day smoker for 30 years but quit smoking after her heart attack. She uses alcohol infrequently. She has a 9 year history of hypercholesterolemia. She is allergic to nuts, shellfish, strawberries and hydralazine. Her medical history also includes diagnosis of osteoarthritis and gout. Her current medications include celecoxib, allopurinol, atorvatastin and daily aspirin and clopidogrel. The patient is admitted to the hospital for a thorough examination.

Based on the limited amount of information given above do you suspect that this patient has developed left sided CHF, right sided CHF, or total CHF, you should also explain how heart failure occurs on each side of the heart and if the entire heart is involved as well?
How do you arrive at your answer to that question?
What is the likely cause for this patients heart failure?
From the information given above, identify three risk factors that probably contributed to the patient's heart attack 5 years ago.

VS BP 100/50, Pulse 135, Resp 28 and labored, Temp 98.5, Wt 215, Ht 5'8", Patient is anxious.

HEENT Exam totally normal.
Skin Pale with cool extremities and is diaphoretic.

Neck Supple with no bruits over carotid arteries. No thyromegaly or adenopathy. Positive for JVD (jugular venous distention) and positive for HJR (hepatojugalar reflex).

What can you say about this patient's blood pressure and what makes up the actual blood pressure ?
Why might this pt be tachycardiac? Why might this patient be tachypneic?

Explain the pathophysiology of the abnormal skin manifestations.
Do abnormal findings in the neck (JVD and HKR) suggest left heart failure, right heart failure, or total CHF or any combination?

Lungs: Bibasilar rales with auscultation. Percussion was resonant throughout.

Heart: PMI (point of maximal impact) displaced laterally. Normal S1 and S2 with distinct S2 at apex. No friction rubs or murmurs.

Abdomen: Soft to palpation with no bruits or masses. Significant hepatomegaly and tenderness observed with deep palpation.

Extremities: 2+ pitting edema in feet and ankles extending bilaterally to mid calf region. Cool sweaty skin. Radial, dorsal pedis and posterior tibial pulses present and moderate in intensity.

Neurological: Alert and oriented x 3 (place person and time). Cranial and sensory nerves intact. DTRs (deep tendon reflexes) 2+ and symmetric. Strength is 3/5 throughout.

Chest x-ray: Prominent cardiomegaly with perihilar shadows consistent with pulmonary edema. (you can see an x-ray like this in the unit section)

EKG: Sinus tachycardia with waveform, abnormalities consistent with LVH (left ventricular hypertrophy). Pronounced Q waves consistent with previous myocardial infarction.

ECHOCARDIOGRAM: Cardiomegaly with poor left ventricular wall movement.

Radionuclide imaging: EF (ejection fraction) 39%.

What abnormal cardiac exam and chest x-ray findings closely complement one another?
Which abnormal cardiac exam and EKG findings closely complement one another?

Lab: Na 153, K 3.2, BUN 50, Cr 2.3, Glu 131, Ca 9.3, Mg, 1.9, Alk Phos 81, AST 45, pH 7.35, PaCO2 53 mm Hg, PaO2 65 mm Hg, WBC 5.1, Hct 41%, Hgb 13.7, Plt 220,000, Alb 3.5, TSH 1.9.

What might the abnormal serum Na and K levels suggest?
Explain the abnormal BUN and Cr concentrations?
What might be causing the elevated serum glucose concentrations and what makes blood sugar levels go up?
Explain the abnormal serum AST level.
Explain the abnormal arterial blood gas findings.
Which of the hematologic findings if any are abnormal?
What does the TSH suggest?
Identify 4 drugs that might be immediately helpful to this patient.

Ejection fraction is an important cardiac function parameter that is used to determine the contractile status of the heart and is measured with specialized testing procedures. If a patient has an SV (stroke volume) = 50 and an EDV (end diastolic volume= 200, is the EF abnormally high, low, or normal?

On the second day of admission the pt has substernal chest pain and pressure that radiates into her left arm. She becomes very diaphoretic. Her EKG shows an elevated ST segment in leads II III and IVF. Her troponin is now 12. Blood pressure is now 80/40 and pulse is still 125.

What has happened to the patient? What has happened to the blood pressure and explain why it has happened?

Answer 1

●The patient is experiencing Right sided heart failure.The typical symptoms are is the swelling of ankles and feet ,the other symptoms are breathlessness, weakness and tiredness.

Normal the left side of the heart receives oxygenated blood after purification from the lungs.When the left ventricle cannot function well it leads to retention of fluid in the left ventricle and causing the fluid back in lungs also making has exchange difficult resulting in dyspnea and generalized fluid retention in the body.

The right side of the heart receives the deoxygenated blood when the right ventricle can not pump effectively it leads to retention in the blood vessels it carries leading to leakage in the cells and tissues.This mainly occurs in the lower limbs at ankle and feet causing edema. Simultaneously fluid is retained in lungs causing dyspnea and associated symptoms

When bothe the ventricles cannot pump the blood effectively due to the underlying cause it affects the pulmonary circulation first leading to difficulty in breathing followed by fluid leakage due to electrolyte imbalance, acid base imbalance leading to retention of fluid in abdomen, anasarca ,thus increasing weight and causing other symptoms.

●The swelling in the ankles and feet are the typical indicator of right sided heart failure

●The like cause for patient's heart failure are due to

• Cardiovascular disease (Transmural anterior wall MI,)
• Family history of atherosclerosis
• Hypercholesterolemia
• Smoking
• Alcohol

●The probable risk factors before five years are

• Smoking
• Family history
• Hypercholesterolemia