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Symptoms of the RVFEdema of the lower extremities, sacrum, abdominal wall. Fullness in the right upper quadrant of the abdomen. Abdominal distension (ascites) Fatique Dizziness Facial engorgement Pulsation in neck and face, fullness in the neck (tricuspid regurgitation) Nausea, vomiting, anorexia Syncope In addition, patients may be depressed, complain of drug – related side effects. Visual examination The patient may look ill and exhausted, with cool peripheries, peripheral cyanosis, peripheral edema and, probably with ascites. Palpation Pulse: resting tachycardia, pulsus altermans. Systolic BP decreased, narrow pulse pressure. An abnormal pulsation (heave) is felt at the right sternum border near the fifth intercostals space if the right ventricle is enlarged. Percussion The right border of relative heart dullness drifts right from the sternum due to enlarged right ventricle. Auscultation of the heart The weakened S1 and S2, S3 gallop, S4 over the right ventricle. Murmurs of valve disease, systolic murmur of tricuspid regurgitation. Chest: tachypnea and signs of pleural effusions. Abdomen : an enlarged and tender liver, pulsatile in tricuspid regurgitation. Investigations Chest X-ray: 1.Cardiomegaly (cardiothoracic ratio>50 prominent upper lobe veins (upper lobe diversion), 2. peribronchial cuffing, diffuse and intersticial or alveolar shadowing. 3. classical perihilar “bat’s wing’’ shadowing, fluid in the fissures, 4. pleural effusions, 5. Kerley B lines (variously attributed to interstitial edema and engorged peripheral lymphatics). ECG may indicate cause of heart failure (look for evidence of ischemia, MI, or ventricular hypertrophy). It is rare to get a completely normal ECG in chronic heart failure. ECHOCARDIOGRAPHY is the key investigation. It may indicate the cause (MI, valvular heart disease) and can confirm the presence or absence of LV dysfunction. Ejection fraction is used to determinate severity of the LVF: if ejection fraction > 45% heart failure is absent, ejection fraction = 35-45% - mild LVF, ejection fraction = 25-35% - moderate LVF, ejection fraction < 25% - severe LVF. If ejection fraction <20% prognosis is poor. Circulatory collapseis a pathological condition due to losing vessel smooth muscle tone or reducing blood circulation volume. Causes of the losing vessel smooth muscle tone are disorder of their innervations, vessels paresis due to infection or intoxication. Causes of the reducing blood circulation volume are hemorrhage and dehydration. These causes result in widening arterioles and venues, decreasing BP, slowing down bloodstream, diminishing blood circulation and blood accumulation in the blood depot. The cardiac output decreases and the brain circulation becomes insufficient. Acute circulatory collapse: Syncope is a sudden short-time loss of consciousness due to brain ischemia. Shock is a severe life-threatening condition result from influence very strong irritates and accompanying with progressive disorders of essential functions and critical disorder of hemodynamics. There are two phases of the shock: early stage- patient is exciting and inadequately mobile. Pulse is frequent and good filling, BP is increased, tachypnoea latestage - restlessness, apprehension, irritability, thirst from decreased cerebral tissue perfusion, tachycardia, low filling pulse and tachypnea, hypotension, altered level of consciousness, oliguria, anuria, hypothermia. Collapseis an abrupt decreasing vessel smooth muscle tone or acute reducing blood circulation volume. It develops critically. Patient fills visual impairment, buzzing in the ears, weakness and then losses consciousness. He has pale skin, cold sweat and extremities, vein collapse, tachypnea, hypotension, thready pulse. Acute pulmonary edema is a dramatic and life-threatening manifestation of acute left ventricle failure secondary to sudden onset of pulmonary venous hypertension. A sudden rise in left ventricle filling pressure to high levels results in rapid movement of plasma fluid through pulmonary capillaries into the interstitial spaces and alveoli. The patient presents with extreme dyspnea, tachypnea, hyperpnea, cyanosis, restlessness and anxiety with a sense of suffocation. The pulse may be thready, and the BP may be high. Respirations are grunting and labored with inspiration, expiration is prolonged. Rales are widely dispersed over both lung fields anteriorly and posteriorly. Reference sources 1. Harrison’s Principles of Internal Medicine – 15th ed. – ed. E. Braunwald and al.- McGraw – Hill, 2001 – p. 1318 – 1323 2. Medicine/ed. By Allen R. Myers – 3rd ed. (National medical series) – Williams & Wilkins, 1997 – p. 1-7 Test for self – control 1 1. Heart failure is an ... a) Incompetence of the heart to provide the body’s requirements at blood circulation during rest b) Incompetence of the heart to provide the body’s requirements at blood circulation during rest and physical activity c) Incompetence of the heart to provide the body’s requirements at blood circulation during physical activity d) Incompetence of patient to hold stable level of blood pressure and pulse rate. e) Nothing from above 2. Which symptoms characterize LVF? a) Nocturia, hepatomegaly, nocturnal cough. b) Dyspnea, chest pain, dry cough. c) Dyspnea, orthopnea, nocturnal cough. d) Edema of the lower extremities, hepatomegaly. e) All from above. 3. Which symptoms characterize RVF? a) Nocturia, hepatomegaly, nocturnal cough. b) Edema of the lower extremities, hepatomegaly. c) Edema of the lower extremities, nocturnal cough d) Dyspnea, chest pain, dry cough. e) Nothing from above 4. What symptom does not characterize LVF? a) Dyspnea b) Orthopnea c) Cough d) Nocturia e) Edema of the lower extremities 5. What symptom does not characterize RVF? a) Edema of the lower extremities b) Hydrotorax c) Hepatomegaly d) Ascites e) Dry cough Dyspnea, chest pain, dry cough. 6. What diseases can lead to heart failure? a) Arterial hypertension b) Valvular heart disease c) Myocardial infarction d) Cardiomyopathies e) All from above 7. What are percussion findings at the patients with LVF? a) The left border of relative heart dullness drifts left b) The right border of relative heart dullness drifts right c) The right border of relative heart dullness drifts left d) Nothing from above e) Depend on clinical situation 8. What are percussion findings at the patients with RVF? a) The left border of relative heart dullness drifts left b) The right border of relative heart dullness drifts right c) The right border of relative heart dullness drifts left d) Nothing from above e) Depend on clinical situation 9. What are auscultation findings at the patients with heart failure? a) Weakened S1 and S2, S3 gallop b) Weakened S1 and systolic murmur c) Depend on disease which lead to heart failure d) Accented S2 over aorta, diastolic murmur e) Weakened both sounds 10. What are the lung auscultation findings at the patients with heart failure? a) Vesicular breathing, basal rales b) Diminished vesicular breathing c) Diminished vesicular breathing and crepitation d) Vesicular breathing and pleural friction rub e) Nothing from above
Test for self – control 2
11. What BP does patient with heart failure have? a) Systolic BP decreased, narrow pulse pressure b) Systolic BP increased, wide pulse pressure c) Systolic BP normal, increased diastolic BP d) Depend on clinical situation e) Nothing from above 12. If patient has heart disease, but ordinary activity does not cause dyspnea, he has… a) I functional class of HF b) II functional class of HF c) III functional class of HF d) IV functional class of HF e) Nothing from above 13. If patient has dyspnea on ordinary activity, he has… a) I functional class of HF b) II functional class of HF c) III functional class of HF d) IV functional class of HF e) Nothing from above 14. If patient has dyspnea at rest and all activity causes discomfort, he has… a) I functional class of HF b) II functional class of HF c) III functional class of HF d) IV functional class of HF e) Nothing from above 15. If less than ordinary activity causes dyspnea at the patient, he hes… a) I functional class of HF b) II functional class of HF c) III functional class of HF d) IV functional class of HF e) Nothing from above 16. Ecchocardiography: a) May indicate the cause of HF b) Can confirm the presence or absence of LV dysfunction c) Is the less useful than chest X – ray for recognizing HF d) a and b e) All from above 17. Ejection fraction is used to determinate… a) Cause of the LVF b) Severity of the LVF c) Cardiothoracic ratio d) a and b e) Nothing from above 18. If patient has ejection fraction 37 % he has… a) No heart failure b) Mild LVF c) Moderate LVF d) Severe LVF e) Terminal LVF 19. If patient has ejection fraction 44 % he has… a) No heart failure b) Mild LVF c) Moderate LVF d) Severe LVF e) Terminal LVF 20. If patient has ejection fraction 23 % he has… a) No heart failure b) Mild LVF c) Moderate LVF d) Severe LVF e) Terminal LVF
Control questions:
Practical task 1.Revealing and assessment of symptoms and signs of the left and right ventricle failure. 2. Revealing and assessment of functional data at patients with heart failure. Professor assistant Demchuk A.V. Date: 2015-12-17; view: 704
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