Running head: CARDIOVASCULAR CLINICAL

Cardiovascular Clinical Case Study

Cool Hand Luke
Tennessee State University
Regents Online Degree Program

Fall Semester
October 19, 2014
I. Introduction Case Study Parameters

CARDIOVASCULAR CLINICAL CASE STUDY

This case scenario involves a 74-year-old female patient i.e. Ms. Martha Wilmington
exhibiting symptoms of dyspnea and some degree of edema. A patient health history revealed
that she once suffered from rheumatic fever while in her twenties which was then reported to her
physician as progressively intense shortness of breath particularly noted upon exertion. Upon
further interview, the patient also revealed that the she was experiencing a significant degree of
ankle swelling which has equally gotten worse over the last past few years.
Both of these problems seem to have developed relatively at the same time over the past
two months. Interestingly, the patient states that her edema has made it tough to put on her
shoes, especially toward the end of the day. The patient mentions that within the past week she
has had a decreased appetite along with some vomiting, nausea, and noticeable tenderness
located in her right upper region of her abdomen.
After the initial assessment and upon conducting a physical examination, an inspection
revealed that the patient's jugular veins were noticeably distended. Upon auscultation of the
heart, it was also revealed that the patient seem to have a rumbling systolic murmur of low-pitch,
chiefly heard best over her left upper sternal border. Lastly, the patient appeared to have a third
heart sound i.e. (S3).
This individual goals of this clinical assignment are to: (1) determine what is causing the
murmur, (2) determine what is causing the third heart sound (S3), (3) explain if the patient's
history of rheumatic fever is relevant to her current symptoms, (4) delineate if an x-rayed cardiac
silhouette normal diameter her heart rules out possible cardiac problems, (5) explain the reasons
why the patient also presents with hepatomegaly and a moderate degree of ascites, (6) explain
also why the patient presents with pitting edema, (7) explain why wearing support stockings
would help her, (8) determine if the patient is experiencing preload or afterload, (9) deduce and

CARDIOVASCULAR CLINICAL CASE STUDY

name the medical condition for which the patient is presenting, (10) determine how the patient's
body may attempt to compensate for the presence of this condition, and (11) develop a medical
care plan for this patient.

CARDIOVASCULAR CLINICAL CASE STUDY

II. What is causing this murmur?

According to this scenario the low pitched rumbling sound was specifically heard clearest
at the left upper sternal board of the patient's chest (Seidel et al, 2011). This area houses the
pulmonic valve (Dains, Baumann, Scheibel, 2012). The rumbling low-pitched sound is usually
congruent to narrowing valve (Bickley, 2009). Medically, this is refer to as pulmonic valve
stenosis, which is usually caused by the valves themselves failing to completely open
(Sochalski et al, 2009). This failure creates a situation where the patient's blood flow meets
advanced resistance during ventricular contraction (Seidel et al, 2011). This resistance
subsequently produces turbulent blood flow commonly noticed upon auscultation as a low
pitched sound medically referred to as a murmur (Dains, Baumann, Scheibel, 2012).
III. What is causing her "S3" heart sound?
The third heart sound (S3) is commonly recognized as a byproduct of patients afflicted
with congestive heart failure (Bickley, 2009). Krumholz et al, (2006) states that patients with
congestive heart failure have an increased amount of tension placed against their ventricular
wall causing an unnatural toughening (Seidel et al, 2011). When blood arriving from the
atrium meets an otherwise dissenting ventricular wall during the diastole phase of the heart
beat, the third heart sound (S3) is created (Bickley, 2009).
IV. Is her history of rheumatic fever relevant to her current symptoms? Explain.
Further test would have to be conducted to definitively determine if the patient's history
with rheumatic subsequently caused the patient's current symptoms (Dains, Baumann,

CARDIOVASCULAR CLINICAL CASE STUDY

Scheibel, 2012). The origin of rheumatic fever usually derives from an infection caused by the
streptococcus pyogenes microorganism (Seidel et al, 2011). While this bacterial infection does
have a tendency to target cardiac tissue, the effect is usually focused upon the mitral or aortic
valves (Bickley, 2009). This patient has a pulmonic-based stenotic problem which is located
on the right side of the heart, suggesting that rheumatic fever may not be the culprit. But
Naylor et al (2004) states that this bacteria can also cause generalized destruction of the
endocardium which features all valves, which equally suggests that the patient's history with
rheumatic fever cannot be ruled out (Dains, Baumann, Scheibel, 2012).
V. A chest X-ray reveals a cardiac silhouette that is normal in diameter. Does this rule out a
possible problem with Martha's heart? Explain.
The initial response to this question is negative, that is to say an x-ray showing a normal
diameter of the patient's cardiac silhouette does not necessarily suggest the absence of a
problem. Seidel et al (2011) states that a patient afflicted with pulmonary stenosis may
eventually develop concentric hypertrophy with respect to the thickness of the ventricle wall.
However, this may not necessarily effect the overall diameter of the heart, and certainly not to
the degree noticeable on an x-ray cardiac silhouette (Sochalski et al, 2009).
VI. You examine Martha's abdomen and find that she has an enlarged liver ("hepatomegaly")
and a moderate degree of ascites (water in the peritoneal cavity). Explain these findings.
The answer is derived from a healthy understanding of anatomy and physiology. The
patient's enlarged liver and peritoneal cavity problems are directly linked to increased systemic
venous pressure created by her pulmonary stenosis (Seidel et al, 2011). This is actually

CARDIOVASCULAR CLINICAL CASE STUDY

evidenced by the observed jugular vein distension noticed during the inspection aspect of the
physical assessment (Sochalski et al, 2009). A significant degree pressure develops in the
patient's right ventricle backing up through her central systemic veins. The peripheral systemic
veins are subsequently effected which places pressure in the inferior vena cava and lastly
hepatic vein leading to the liver itself (Bickley, 2009). This pressure creates extra fluid filling
into the interstitial spaces of the liver and peritoneal cavity which causes the swelling (Seidel et
al, 2011).
VII. Examination of her ankles reveals significant "pitting edema." Explain this finding.
Congruent to the problem addressed in question six, the patient's has an elevated systemic
venous pressure problem (Sochalski et al, 2009). This problem causes fluid to venture from
the peripheral capillaries into the interstitial regions of the patients lower extremities,
particularly her ankle and feet which as closest to the ground and most susceptible to weight
and gravity (Sochalski et al, 2009). This set of circumstances creates the conditions leading to
edema, which can be alleviated through a practiced routine of rest with leg and foot elevation
throughout the day (Seidel et al, 2011).
VIII. She is advised to wear support stockings. Why would this help her?
Actually, support stockings work to produce a counter force for the purpose of placing
externalized pressure upon the patient's lower extremities (Sochalski et al, 2009). The extra
fluid which is squeezed into the interstitial spaces by systemic venous pressure would instead
be forced into the lymphatic vessels, which will then be routed back up through the patient's
cardiac system (Bickley, 2009). Wearing properly fitting support stocking is an inexpensive
yet efficient way to control edema in the lower extremities (Bickley, 2009).

CARDIOVASCULAR CLINICAL CASE STUDY

IX. Which term more accurately describes the stress placed upon Martha's heart - increased
pre-load or increased afterload?
It appear the answer is increased afterload. Afterload is basically ventricular pressure
arriving at the end of systole (Bickley, 2009). At this time, ejection essentially ceases for a
moment because the ventricular pressure created cardiac contractions is considerably lesser
than what is produced by arterial pressure (Sochalski et al, 2009).
X. What is the general term describing Martha's condition?
Based upon the assessment and subsequent analysis, this patient appears to have rightsided congestive heart failure evidenced by systemic edema (Sochalski et al, 2009). The
enlargement of the patient's liver and peritoneal cavity help to support this conclusion (Dains,
Baumann, Scheibel, 2012).
XI. How might Martha's body compensate for the above condition?
The patient's natural body's homeostasis would attempt to compensate the right ventricle's
decrease in stroke volume by increasing the heart rate and cardiac strength of contraction in
order to provide adequate cardiac output for the body's oxygen and metabolic demands
(Sochalski et al, 2009). If the patient was younger, this degree of compensation would
probably suffice (Bickley, 2009). However, the patient's advanced age may require the body to
shun blood to the more vital organs such are the heart and brain away from the lesser organ
systems i.e. urination and digestion by a series of vasodilatation and vasoconstriction
baroreceptor reflex activity (Dains, Baumann, Scheibel, 2012).

CARDIOVASCULAR CLINICAL CASE STUDY

XII. Develop a Medical Plan of Care.

The first order of business would be to prescribe medication that would reduce the
patient's cardiac workload (Bickley, 2009). ACE inhibitors are considered the gold standard
with respect to this task, the only exception would be the statistics which indicates caution
when prescribing this category of drug to certain ethnic groups such as African Americans
because of the studies which indicate less than favorable outcomes (Bickley, 2009). However,
this will not be a problem with the current patient.
Since water retention and edema may be a secondary problem, a diuretic may also be
prescribed to reduce fluid accumulation (Sochalski et al, 2009). Lastly, spironolactone may
also be prescribed to help reduce salt retention (Dains, Baumann, Scheibel, 2012). The patient
would also be instructed to make some lifestyle changes. Generally, she would be instructed to
rest often and reduce any extra strain or exertion (Sochalski et al, 2009). Also, she would be
asked to reduce salt in her foods and restrict the amount of liquids per day. Lastly, although the
scenario did not indicate otherwise, the patient may be warned about the dangers of smoking
and or alcohol drinking (Bickley, 2009).

CARDIOVASCULAR CLINICAL CASE STUDY

References
Bickley, L. S. (2009). Bates' guide to physical examination and history taking (10th ed.),
Philadelphia, PA: Wolters Kluwer Health | Lippincott Williams & Wilkins.
Dains, J.E., Baumann Ciofu, L., Scheibel, P. (2012). Advanced Health Assessment and Clinical
Diagnosis in Primary Care (4th ed). St. Louis Missouri: Elsevier Mosby.
Krumholz, H. M., P. M. Currie, B. Riegel, C. O. Phillips, E. D. Peterson, R. Smith, C. W. Yancy,
and D. P. Faxon. (2006). A taxonomy for disease management: A scientific statement
from the American Heart Association Disease Management Taxonomy Writing Group.
Circulation 114(13):14321445.
Naylor, M. D., D. A. Brooten, R. L. Campbell, G. Maislin, K. M. McCauley, and J. S. Schwartz.
(2004). Transitional care of older adults hospitalized with heart failure: A randomized,
controlled trial. Journal of the American Geriatrics Society 52(5):675684.
Seidel, Henry M., Ball, Jane W.,Dains, Joyce E.,Flynn, John A.,Solomon, Barry S., Stewart,
Rosalyn W. (2011). Mosbys Guide to Physical Examination (7th ed) St. Louis,MO:
Mosby
Sochalski, J., T. Jaarsma, H. M. Krumholz, A. Laramee, J. J. V. McMurray, M. D. Naylor, M. W.
Rich, B. Riegel, and S. Stewart. (2009). What works in chronic care management? The
case of heart failure. Health Affairs 28(1):179189.