History: Martha Wilmington, a 74-year-old woman with a history of rheumatic fever while in her twenties, presented to her physician with complaints of increasing shortness of breath (“dyspnea”) upon exertion. She also noted that the typical swelling she’s had in her ankles for years has started to get worse over the past two months, making it especially difficult to get her shoes on toward the end of the day. In the past week, she’s had a decreased appetite, some nausea and vomiting, and tenderness in the right upper quadrant of the abdomen.
On physical examination, Martha’s jugular veins were noticeably distended. Auscultation of the heart revealed a low-pitched, rumbling systolic murmur, heard best over the left upper sternal border. In addition, she had an extra, “S3” heart sound.
Using the internet, do any applicable searches to give a reasonable scientific explanation to the questions below. Understanding figure 20-13 in your textbook also may add some insight to these questions.
You may find the following links useful to aid you answering these questions:
Congested Heart Failure Paper
ABC of Heart Failure
What is causing this murmur? Perhaps there has been narrowing of Martha’s pulmonary semilunar valve which is located between the right ventricle and the pulmonary artery.
The closing of this valve is heard best over the left upper sternal border. As stated above, this is where auscultation of the heart revealing a low-pitched, rumbling systolic murmur. A murmuring sound is heard due to the high resistance to blood being pumped through.
2) What is causing her “S3” heart sound? An S3 sound is an extra sound indicating abnormal blood pressure within the heart, namely against the ventricle walls during diastole (relaxation). Blood seems to be flowing too rapidly into the ventricles during diastole. She may have ventricular walls that have become hardened and thus not relaxing as needed in order to fill with ease. As the blood quickly flows in, it will hit the hardened walls, creating an extra sound. In congestive heart failure, preload and contractility are major factors in the improper functioning of the heart as a pump.
3) Is her history of rheumatic fever relevant to her current symptoms? Explain. Rheumatic fever caused by Group A Streptococcus bacteria may cause damage to heart tissues including valves. Overtime, congestive heart failure may have developed. However, the pulmonary semilunar valve seems to be the issue in this case study, whereas rheumatic fever normally affects left heart tissue. 4) A chest X-ray reveals a cardiac silhouette that is normal in diameter. Does this rule out a possible problem with Martha’s heart? Explain. No, a normal diameter of a cardiac silhouette does not rule out a problem with Martha’s heart. The heart adapts and will compensate for damage in order to still function optimally. The right ventricle, in this case, will become stronger in order to push the same amount of blood (stroke volume) through the narrowed pulmonary semi-lunar valve. This thickening doesn’t necessarily change the inner diameter.
5) You examine Martha’s abdomen and find that she has an enlarged liver (“hepatomegaly”) and a moderate degree of ascites (water in the peritoneal cavity). Explain these findings. The increased resistance of blood flow through the pulmonary semilunar valve from the right ventricle backs up the pressure of blood flowing into the right atrium. This back flow pressure builds up in the body as systemic pressure, increasing hydrostatic pressure which increases fluid build-up (ascites) in the peritoneal cavity and liver, enlarging the liver.
6) Examination of her ankles reveals significant “pitting edema.” Explain this finding. Fluid builds up in the interstitial space of her extremities (i.e. ankles) due to the changes in the hydrostatic pressure caused by the back-flow pressure originating in the heart.
7) She is advised to wear support stockings. Why would this help her? Support stockings could be used. I worked at a Med-Spa and the doctor would advise his patients to wear compression hoses after laser vein treatments if there were no other individual contraindications of use. Compression hoses prevent fluid from accumulating in surrounding tissues and interstitial spaces by directing excess fluid into other blood vessels and the lymphatic system.
8) Which term more accurately describes the stress placed upon Martha’s heart — increased pre-load or increased afterload? Increased after-load describes the stress placed upon Martha’s heart. Afterload is the pressure that the heart pumps blood against. There is increased pressure associated from left ventricular damage and narrowing of the semi-lunar valve in Martha’s diseased state, leading to the resistance of blood flow.
9) What is the general term describing Martha’s condition? Right-sided congestive heart failure is the general term for Martha’s condition.
10) How might Martha’s body compensate for the above condition? Martha’s sympathetic nervous system will begin to predominate, causing constriction of blood vessels so that important organs will regain necessary delivery of blood. Also, heart rate and stroke volume affect cardiac output. In Martha’s case, cardiac output is affected due to a decrease in stroke volume. Higher resistance to blood flow decreases the amount of blood pumped by her ventricles, so the heart compensates in order to function optimally. Increased contractibility or the increased rate at which her heart pumps is indicative of this compensation.
11) Martha is started on a medication called digoxin. Why was she given this medication, and how does it work? Digitoxin (digitalis) increases the strength and length ventricular contraction which slows heart rate by reducing sympathetic activity. Her right ventricle will then pump more efficiently.
12) 12. Two weeks after starting digoxin, Martha returns to the physician’s office for a follow-up visit. On physical examination, she still has significant hepatomegaly and pitting edema, and is significantly hypertensive (i.e. she has high blood pressure). Her physician prescribes a diuretic called furosemide (or “Lasix”). Why was she given this medication, and how does it work? Digitoxin is commonly given in conjunction with a diuretic. The use of a diuretic manages edema, a symptom of congestive heart failure. Increased urination will rid her body of excess ions, reducing the amount of fluid in the interstitial spaces.
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