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Zorluk: KolayCardiovascular System

A 72-year-old woman comes to the outpatient clinic due to a 4-day history of progressively worsening shortness of breath. She also reports waking up multiple times at night feeling a sensation of suffocation, which is only relieved by sitting upright for several minutes. Her medical history includes long-standing hypertension, type 2 diabetes mellitus, and a 35-pack-year smoking history. Current medications include lisinopril, amlodipine, and metformin. Vital signs show a temperature of 37.0°C (98.6°F), blood pressure of 162/94 mm Hg, pulse of 102/min, and respiratory rate of 22/min. Pulse oximetry is 92% on room air. Examination reveals elevated jugular venous pressure and pitting edema of the lower extremities up to the knees. Which of the following additional physical examination findings is most likely to be present in this patient?

  1. A
    Diffuse expiratory wheezing with a prolonged expiratory phase
  2. B
    Hyperresonance to percussion over bilateral lung fields
  3. A low-frequency early diastolic sound at the cardiac apexCevap
  4. D
    A prominent right ventricular heave with a loud pulmonic component of the second heart sound
  5. E
    Coarse rhonchi that clear completely after coughing

Cevap

A low-frequency early diastolic sound at the cardiac apex
The patient's presentation of progressively worsening dyspnea, orthopnea, paroxysmal nocturnal dyspnea, elevated jugular venous pressure, and bilateral pitting edema is classic for acute decompensated heart failure (ADHF). In the setting of left ventricular failure and volume overload, an abnormal third heart sound (S3 gallop) is frequently auscultated. This low-frequency, early diastolic sound occurs during the rapid filling phase of ventricular diastole and is highly specific for heart failure in older adults. It is heard best at the cardiac apex with the bell of the stethoscope while the patient is in the left lateral decubitus position.

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1
Identify the primary clinical syndrome from the patient's history and vital signs.
The patient presents with orthopnea, paroxysmal nocturnal dyspnea, elevated jugular venous pressure, and bilateral lower extremity edema.
These are classic signs of acute decompensated heart failure (ADHF) leading to systemic and pulmonary volume overload.
2
Differentiate the cause of dyspnea from other possible etiologies.
Despite the patient's smoking history, the specific presence of isolated volume overload signs strongly points to a cardiogenic etiology rather than a primary pulmonary exacerbation like COPD.
COPD exacerbations do not typically present with acute orthopnea, paroxysmal nocturnal dyspnea, and rapid-onset peripheral edema.
3
Determine the expected physical examination findings for the confirmed diagnosis.
Left ventricular failure and subsequent volume overload typically produce a third heart sound (S3).
An S3 gallop is a low-frequency early diastolic sound heard best at the cardiac apex and is highly specific for heart failure in older adults.

Anahtar Kavram

Patients with acute decompensated heart failure present with signs of volume overload (orthopnea, elevated jugular venous pressure, edema) and often have an S3 gallop, an early diastolic sound caused by rapid ventricular filling into a non-compliant or overfilled left ventricle.
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Cardiovascular System

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