The first patient is a 39 year old male that presents to the ER with fatigue and

Question

The first patient is a 39 year old male that presents to the ER with fatigue and shortness of breath. He has a heart rate of 133 bpm, 155/90 bp and a S2 associated with a harsh systolic ejection murmur. In addition he has hemoptysis and complains that his dyspnea is worse at night. He has bilateral rales and peripheral cyanosis. A chest x-ray demonstrates left ventricular hypertrophy.

2. The echocardiogram shows aortic stenosis, with calcification of the aortic valve and thickening of the left ventricular myocardium.  

When does the aortic valve open? ___________

How would the valve problem change the cardiac output? ________________________

What has the heart done to improve cardiac output? ________________________

(Think in terms of CO = HR x SV)

3. This patient has increased pulmonary venous pressure of over 25 mm hg. Can you explain the hemoptysis and rales?  

Why is it worse at night? (Unless he falls asleep watching TV, sitting up….hint, hint)

Explanation / Answer

2a. ANS: Once the ventricles are full, they contract. As the left ventricle contracts, the mitral valve closes and the aortic valve opens. The closure of the mitral valve prevents blood from backing into the left atrium and the opening of the aortic valve allows the blood to flow into the aorta and flow throughout the body.

2b. ANS: Valve problem can able to take place changes in cardiac output.

The majority of serious heart valve problems affect the mitral and aortic valves; disease of the tricuspid and pulmonary valves is fairly rare but more common in India and other developing countries than in North America or Western Europe.

Ex: Mitral regurgitation (Acute valve failure)

Once acute valve failure in the context of a low-cardiac-output state has been diagnosed, urgent referral to the cardiothoracic surgeons for consideration of surgery needs to occur.

2c. ANS: Cardiac output is dependent on stroke volume and heart rate. So the heart can increase the strength of its contractions and the amount of blood ejected with each beat, thereby increasing cardiac output.

3a. ANS: Normal pulmonary artery systolic pressure at rest is 18 to 25 mm Hg, with a mean pulmonary pressure ranging from 12 to 16 mm Hg. This low pressure is due to the large cross-sectional area of the pulmonary circulation, which results in low resistance. An increase in pulmonary vascular resistance or pulmonary blood flow results in pulmonary hypertension.

Cardiovascular conditions that result in pulmonary venous hypertension can cause cardiac hemoptysis. The most common of these is left ventricular systolic heart failure.

3b. ANS: The hemoptysis occurs at night, or in the early morning hours. In eleven out ofsixteen of the reported cases it will be seen that this happened. In hemoptysis, the blood generally arises from this bronchial circulation, except when pulmonary arteries are damaged by trauma.

Fever, night sweats and chest pain and dyspnea (pneumonia, pulmonary embolism) due to these symptoms patients conditions was worse at night.

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