Question

Chief Complaint: 74-year-old woman with shortness of breath and swelling. 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. 9. What is the general term describing Martha's condition? 10. How might Martha's body compensate for the above condition? 11. Martha is started on a medication called digoxin. Why was she given this medication, and how does it work?

Question:

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????

Thanks

Answer 1

9. The general condition describing Martha's condition is Congestive heart failure. The heart is unable to pump blood to meet the body demands in the required amount and hence, its efficiency has been reduced. Tenderness in the right upper quadrant shows an inflammation in the liver as it covers the whole of right upper quadrant in humans. The distension of the jugular veins shows the inefficiency of the valves to pump blood, thus causing the backflow which ultimately causes edema. The presence of S3 sound confirms the presence of congestive heart failure.

10. In congestive heart failure, there is an inadequate or inefficient contraction of the valves of the heart causing a reduced cardiac output. Martha's body can compensate to maintain the cardiac output in the following ways:-

A. Increasing sympathetic activity. B. Increasing renin- angiotensin- aldosterone system. C. Myocardial hypertrophy and remodeling.

11. Digoxin is a cardiac glycoside which is given to the patients of congestive heart failure. Digoxin works by binding and inhibiting the Na+ K+ ATPase which causes an increased intracellular Na+. This leads to the decrease in the extrusion of the Ca2+ by the Na+/ Ca2+ exchanger, which ultimately leads to an increase in the intracellular Ca2+. There is an increase in Ca2+ uptake which is stored in the sarcoplasmic reticulum. Increased amount of Ca2+ is released during each action potential from the sarcoplasmic reticulum. The increased availability of Ca2+ ions occurs for excitation- contraction coupling which ultimately increases myocardial contractility, thus causing an increased cardiac output. Digoxin provides a positive ionotropic effect. This decreases pulmonary congestion and systemic venous pressure.

12. Martha was prescribed furosemide (lasix) because it is loop diuretic. The diuretics promotes water and salt excretion which decreases their circulating volume. This decreases preload and improves cardiac function, decreases dyspnea and peripheral edema. It also provides relief with the symptoms of congestion. It promotes diuresis and thus, decreases the blood pressure.