Question

Emma, 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, Emma'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. A chest X-ray reveals a normal cardiac silhouette that is normal in diameter, but her physical examination reveals hepatomegaly and ascites, as well as pitting edema in her ankles. She is advised to wear support stockings and given a prescription for digoxin. Two weeks later she returns to the office for a follow-up visit; upon 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").

1. What is meant by the terms “hepatomegaly” and “ascites” and why are they happening? Why are her jugular veins distended? Be specific in terms of blood pressure and Starling forces.

2. What is pitting edema and what is causing it?

3. Why is she advised to wear support stockings? If she had atherosclerosis or blockage of a femoral artery, would this be an advisable diagnosis? Why or why not?

4. Is the stress being placed on Emma's heart pre-load or after-load and why?

Answer 1

Question no 1

Hepatomegaly us the enlargement of liver due to etiological or position problems

Ascitic is the accumulation of fluid in the peritoneal cavity more than 15 liters in quantity

They are happening as the patient is having symptom related to backward heart failure which cause increase in the portal hypertension so this occur resulting in ascitis and hepatomegaly. The fluid and molecules in it move out of blood vessel when pressure increases according to Starlin forces .

So the Increase in the portal pressure leads to forcing our of fluid and albumin out of blood vessel causing accumulation of fluid

Question no 2

Pitting edema is the accumulation of fluid which is forced out of blood vessel due to fluid overload or injuries to the blood vessel. It is graded as 1,2 and 3. When we press our 2 fingers into the edema a pit will be formed

Question no 3

As there is decreased venous pressure and immobility there is risk of deep vein thrombosis occurance . So she is adviced to were stockings . This will help to increase the fluid return into heart

If femoral atherosclerosis was the problem then the cause would be reduce blood flow to the extremity and force in the left side of heart would have increased leading to left ventricular hypertrophy

Question no 4

The stress by Emma's heart is due to preload it is a backward heart failure that means the old comming to heart is blocked