follow up patients

3531376
89 y/o man, heart failure

1414720
82 y/o man, FUO

physical examination of cardiovascular system

abdomen:
pulsatile, expansible abdominal, mass: aortic aneurysm
large, tender liver: heart failure, constrictive pericarditis
systolic hepatic pulsation: TR
palpable spleen: severe heart failure, infective endocarditis
ascites: heart failure, constrictive heart failure (especially when ascites is out of proportion of limbs edema)

extremities:
ankle-brachial index (ABI): consider to be abnormal when <0.9, critical stenosis when < 0.3
thrombophlebitis: pain in the calf or thigh, with edema

arterial pressure pulse:

pulsus parvus: small weak pulse, common condition with decreased cardiac output

pulsus tardus: delayed systolic pulse, severe AS

pulsus bisferiens: two systolic peak, AR, or hypertrophic cardiomyopathy 

pulsus alternans: regular rhythm with regular alternation of the pressure pulse amplitude, severe impairment of

                          LV function

pulsus paradoxus: systolic pressure decreased> 10 mmHg when inspiration, cardiac temponade, severe

                            lung disease, severe vena cava obstruction

a: atrial contraction 

c: TV bulging into RA when RV isovolumetric systole 

x: atrial relaxation when RV contraction 

v: right atrial volume increased when RV systole and TV close 

y: RV pressure decline and TV open

abdominal-jugular reflex: increased upper level of venous pulsation when abdominal compression (>10 seconds), indicate heart failure or TR

Kussmaul sign: increased rather than decreased CVP level during inspiration, indicate severe right-heart

                       failure

Precordial palpation:

normal LV apex impulse: mid-clavicular line, 4th or 5th intercostal space

LV hypertrophy: lateral and downward displacement of LV apex impulse 

RV hypertrophy: sustained systolic lift at lower left sternal border 

MR: left parasternal lift due to RV anterior displacement (compressed by enlarged LA)

visible or palpable pulmonary flow over the left 2nd intercostal space: pulmonary hypertension

 

 

Cor pulmonale

definition:
pulmonary heart disease, excluding congenital heart disease, or right heart disease induced by left heart

etiology:
any pulmonary vascular or parenchymal disease can lead to cor pulmonale
50% cases were due to COPD

pathophysiology:
RV failure due to elevated pulmonary vascular pressure
acute: RV dilation without hypertrophy
chronic: RV dilation and hypertrophy

symptoms and signs
dyspnea, orthopnea, limbs edema, ascites
holosystolic murmur (TR murmur), increased with inspiration (Carvallo's sign)
Prominent V waive

diagnosis
1. exclude LV failure induced RV failure
2. EKG: P pulmonale, RV hypertrophy, right axis deviation
3. EKG: engorged pulmonary artery

treatment:
1. treat underlying pulmonary diseases
2. diuretics
3. digoxin: unclear role, should be administered with low dose

heart failure

definition
abnormal cardiac structure or function, which leads to signs (edema, rale) and symptoms (fatigue, dyspnea )

etiology:
75% due to CAD and HTN in developed country

pathogenesis
1. index events
2. compensatory mechanism
    a. RAA system
    b. adrenergic nerve system
    c. increased myocardial contratility

basic mechanism
1. systolic dysfunction
2. diastolic dysfunction
3. LV remodeling

Clinical menifestation
1. fatigue and dyspnea
2. orthopnea and nocturnal cough
3. Paroxysmal nocturnal dyspnea
4. Cheyne-Stoke respiration
5. Acute lung edema
6. Anorexia, nausea
7. Nocturia

Physical examination
1. reduced BP and pulse pressure
2. cool extremities
3. Jugular vein engorgement
4. rales and crackles (may be absent in chronic HF due to increased lymphatic drainage)
5. pleural effusion (drain to systemic and pulmonary vein, means bi-ventricular failure)
6. displaced the point of maximal impulse (PMI), usually displaced below the fifth intercostal space and/or lateral to the midclavicular line
7. S3, S4, MR and TR murmur in advaned cases
8. hepatomegaly, ascites
9. peripheral edema

Diagnosis
1. Clinical symptoms/ signs
2. routine lab
3. ECG
4. CXR
5. cardiac echo/ MRI
6. cardiac enzyme

Treatment
1. stage:   A: high risk patients without structural abnormality or symptoms
                B: structural abnormality without symptoms
                C: structural heart disease with symptoms
                D: refractory heart failure
2. factors may precipitate acute decompensation in chronic heart failure patient
    a. dietary
    b. discontinue treatment
    c. MI
    d. arrhythmia
    e. infection
    f. anemia
    g. medication:
        NSAID, CCB, Beta-blocker, Class I anti-arrhythmic drugs
    h. alcohol
    i. pregnancy
    j. worsing hypertension
    k: acute valvular disease
3. Diet
    sodium: 2~3 g/ day
    fluid restriction (< 2 L/ day) is not generally necessary

4. Diuretics
5. ACEI
6. Beta-blocker

7. Aldactone
8. Hydralazine/ Ismo-20
9. Digoxin

Acute heart failure

Theraputic goal
1. stablize hymodynamic
2. treat reversible factors
3. reestablish an effective outpatient medical regimen

LV filling pressure: elevated: wet             normal: dry
Cardiac output:      decreased: cold         normal: warm

Pharmacological management
1. Diuretics
2. Vasodilators
3. Inotropic agents

Mechanical management:
1. IABP
2. ECMO
3. LV assist device
4. heart transplant
 

dizziness

divided into 3 categories:
1. faintness, 2. vertigo. 3. miscellaneous head sensation

faintness: presyncopal syndromes: blurred vision, feeling of warmth, diaphoresis
vertigo: visual, vestibular, or somatosensory disfunction

diabetes ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS)

                        DKA                       HHS
glucose          250~600                 600~1200
sodium           125~135                 135~145
K                   normal to high          normal
Mg                normal                      normal
Cl                  normal                      normal
P                   decreased                 normal
Cr                 slightly increased       moderate increased
osmolatiry     300~320                  330~380
keto              ++++                       +/-
HCO3           <15                         normal
PH                6.8~7.3                    >7.3

DKA:
symptoms and signs
abdominal pain, shortness of breath, polyuria, thirst, nausea, vomiting
dehydration, hypotension, tachypnea, tachycardia, abdominal tenderness, lethargy

precipitating factors:
infection
infarction
insulin administration inadequate
drug
pregnency

management
1. confirm the diagnosis
2. admission
3. check: electrolyte, acid-base, renal function
4. fluid supplement: 2~3 L N/S for the first 1~3 hr (10~15 mL/kg/hr), than shifted to half saline (150~300
                              mL/hr), half saline and 5% glucose when sugar < 250 (100~200 mL/ hr)
5. Insulin regular: 0.1U/kg IV or 0.3 U/kg IM STAT, than 0.1 U/kg/hr continuous infusion (do not use 
                           insuline if K<3.3)

HHS
prototype: elderly, a several week history of polyuria, decreased oral intake, weight loss, with confusion,
                 lethargy, and coma
precipitating factors: infarction, infection, compromised water intake

management: as DKA








                 

hyponatremia

clinical presentation:
asymptomatic,
general malaise, nausea
lethargy, headache, confusion, seizure, coma

blood osmolality:
hyper- hyperglycemia, mannitol
normal- hyperproteinemia, hyperlipidemia, TURP
hypo-    urine osmolality   <100 mosmo/kg or specific gravity< 1.003  -- primary polydipsia
          
             hypovolemic:
             urine sodium concencration  >20  sodium wasting nephropathy, diuretic use, hypoaldosteronism
             urine sodium concentration  <10 extrarenal loss, remote diuretic use, remote vomiting
             euvolemic:
             SIADH, hypothyroidism, alrenal insufficiency
             hypervolemic:
             CHF, cirrhosis

lab:
urine sodium, potassium, osmolality, plasma osmolality

delta Na=Na inf- Na ser/IBW*0.6 +1

http://www.globalrph.com/saline.htm

4476469