Physiology Clinical Case: Mrs. Marie Topics: Microcirculation (edema) & Cardiac Output

Personal Data: Name: Marie. Age: 68 year-old Gender: Female Occupation: Retired nurse (since 15 years-ago).

Patient´s complaint

Tiredness, difficulty sleeping and ankle edema.

History of presenting complain Over the previous 3 weeks she reports a progressive increase in breathlessness, difficulty

sleeping at night, awakening with shortness of breath. She reports that she is able to sleep

better using several pillows to elevate her chest and head (orthopnea). She refers the

presence of ankle edema (+++).

Past medical history Cardiovascular: 13 months earlier, the patient experienced myocardial infarction of the

anterior wall of the left ventricle involving the septum. A stent was placed in the occluded

coronary artery, reestablishing reperfusion.

Past surgical history: hysterectomy at age 50

Past psychiatric history: negative.

Past obstetric/gynecologic: G:2, P:2 (A:0). At age 50 presented severe bleeding that was treated

with hysterectomy.

GI and urinary: several urinary tract infections treated with antibiotics.

Bone and skeletal muscle: moderate osteoarthritis treated with NSAID

No DM

Medications: NSAID, and Ca++ channel blockers.

Allergies: negative

Family history Father: No information

Mother: No information

Social history Smoking history: Negative

Alcohol history: Negative

Recreational drug use or dependence: Negative

Physical Examination VS: T 37°C; HR: 110/min; R: 25/min (tachypnea); sitting BP: 105/70

Head & neck: normal

Lungs: Late inspiratory crackles heard throughout both lung fields.

Heart: 3rd

heart sound is evident.

Abdomen: symmetric, soft, peristalsis is present.

Laboratory Blood test:

Na+ 128 mEq/L (135-145 mEq/L)

K+ 5.4 mEq/L (3.5-5.0 mEq/L)

Urea 6 mMol/L (1.2 – 3.0 mmol/L)

Creatinine 1.6 mg/dL (0.7-1.3 mg/dL)

Imagenology Chest X-rays: confirmed cardiomegaly and interstitial edema.

Echocardiography:

Shows a dilated heart (left ventricular end diastolic distension (650 ml)).

Anterior and septal hypo kinesis compatible with the previous anterior infarction. The

posterior wall was contracting vigorously.

Mitral regurgitation was noted but left atrial size was normal.

EKG: Confirmed sinus tachycardia (110/min). Shows antero-lateral Q waves of previous infarction

Immediate therapeutic strategies Supplemental oxygen, opiates and diuretics.

Discussion of the Case

1. What edema is? Why edema is detrimental for tissue cell functions

2. Indicate the different types of edema and explain its causes.

3. What is the type of edema in this patient? With a flowchart explain the underlying cause

of her ankle edema, from the moment of acute LV myocardial infarction to her actual time

with chronic heart failure; as well include the changes in the Starling forces at the level of

microcirculation.

4. Explain what orthopnea is and what is the mechanism causing the orthopnea in the

patient. Why the patient sleep better using several pillows

5. What coronary vessel is most likely to be involved in the patient’s infarction 13th month

earlier?

6. Draw a graph with the cardiac and vascular function curves and indicate: the

progressive changes from the normal equilibrium point, the acute infarction and the

chronic consequences of the reduced myocardial contractility. (Before the effect of

diuretics)

7. What is the hemodynamic effect of diuretics in this patient?