week3 pbl

PBL 1

"Rumbling Heart"

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PART1

KEYWORDS

31 yearold

tiredness

cough

nocturnal dyspnoea

limb swelling

repeated attacks

sore throat

joint pains

10yrs ago

radial pulse 88bpm

regular rhythm

small volume

HYPOTHESIS

GroupA strep infection.

generalized edema -> CHF (right ventricular)

rheumatic fever (recurrance)

nocturnal dypsnoea and cough -> pulmonary problems

small volume pulse -> LVF

QUESTIONS (What do we want to know?)

whether she completed medication.

new/old infections?

does she suffer from artheritis?

physical exam - osler's nodes, clubbing, splinter haem.

how about heart sounds? murmur?

blood smears to find pathogen

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PART2

KEYWORDS

mid-diastolic

X-ray show large left atrium

ECG right ventricular hypertrophy

echocardiogram 0 calcified mitral valve

diagnosis valvular heart problem

a "drug" prescribed to relieve symptoms

treatment options discussed.

HYPOTHESIS

mid-diastolic -> mitral stenosis

rheumatic infectinon -> mitral stenosis

she had suffered

QUESTIONS

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LEARNING ISSUES

Jones criteria - for rheumatic fever

heart valves, auscultatory findings, know what disease will affect which valves how

other inflammatory diseases

how to find out ejection-fraction? what is the normal value?

assessment for heart failure

causes and complications of heart failure

distinguish between left and right heart failure

X-ray what we can see from it?

echocardiography

ECG

principles of management of Cardiac Failure

measures to reduce incidence of Rheumatic HD

Health education of patients

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vocab

rheumatic disease A type of disease involving inflammation of muscles, joints, and other tissues.

rheumatic heart disease Rheumatic heart disease is a serious complication of rheumatic fever, a disease in which infection of the upper respiratory tract by streptococcal bacteria leads to heart disease. The infection typically affects the heart valves (valvular rheumatic heart disease), but it can also affect other heart structures.

rheumatic fever Rheumatic fever (RF) is an illness which arises as a complication of untreated or inadequately treated strep throat infection. Rheumatic fever can seriously damage the valves of the heart.

http://medical-dictionary.thefreedictionary.com/Rheumatic+fever

ARF is an inflammatory condition that primarily involves the heart, skin, and connective tissues.

it is a complication of URTI caused by group A strep incection and mainly occurs in children and young adults.

(Lilly's)

PSGN haracterized by the sudden appearance of hematuria, proteinuria and red blood cell casts in the urine, edema, and hypertension with or without oliguria. It can follow streptococcal infections. This illness was first recognized as a complication of the convalescence period of scarlet fever in the 18th century.

http://emedicine.medscape.com/article/240337-overview

Infective Endocarditis Infective endocarditis (IE) is an infection of the endocardial surface of the heart.

http://emedicine.medscape.com/article/216650-overview

Myocarditis myocarditis is inflammation of heart muscle (myocardium). It resembles a heart attack but coronary arteries are not blocked.

http://www.nlm.nih.gov/medlineplus/ency/article/000149.htm

http://en.wikipedia.org/wiki/Myocarditis

pericarditis inflammation of the pericardium.

http://en.wikipedia.org/wiki/Pericarditis

group A strep pharyngitis -> 3% of patients develop ARF 2 to 3 weeks after that

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1. Jones criteria

The major criteria include:

carditis

arthritis

sydenham's chorea

subcutaneous nodules

erythema marginatum

The minor criteria include:

fever

joint pain (without actual arthritis)

evidence of electrical changes in the heart (determined by measuring electrical characteristics of the heart's functioning during a test called an electrocardiogram, or EKG) PROLONGED PR INTERVAL

evidence (through a blood test) of the presence in the blood of certain proteins, which are produced early in an inflammatory/infectious disease.

Tests are also performed to provide evidence of recent infection with group A streptococcal bacteria. A swab of the throat can be taken, and smeared on a substance in a petri dish, to see if bacteria will multiply and grow over 24-72 hours. These bacteria can then be specially processed, and examined under a microscope, to identify streptococcal bacteria. Other tests can be performed to see if the patient is producing specific antibodies; that are only made in response to a recent strep infection.

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2. heart valves

40% of patients with RHD has MS.

additional 25% also develop AS or AR

less frequent, Tricuspid is affected.

pathophysiology of valvular diseases

Mitral Stenosis

obstruction to blood flow from LA to LV.

left atrial pressure high, to propel adequate blood into ventricles

reduced LV SV and CO.

high LA pressure -> increased pulmonary venous and capilliary pressures

increased hydrostatic pressure in lungs cause transudation of plasma into lung interstitium and alveoli.

patient may experience dyspnoea and cough.

in severe cases, increase in pulmonary pressure may cause ruprute a bronchial vein into the lung parenchyma, causing hemoptysis.

high LA pressure -> LA diatation

LA dilatation stretch atrial conduction fibers

disrupt integrity of cardiac conduction system -> arrhythmia (fibrillation)

dilated LA + arrhthmia ->

stagation of blood flow

predispose to intra-atrial thrombus formation

thromboembolism

stroke

patients with mitral stenosis may result in 2 distinct forms of pulmonary hypertension.

passive + reactive.

passive

up LA pressure

up pulmonary vasculature pressure

up pulmonary artery pressure

reactive

medial hypertrophy and intimal fibrosis of pulmonary artery

increased arteriolar resistance impede blood flow from into engorged pumonary capilliary thus reduce capilliary h.pressure (this is good)

decreased blood flow thru the pulmonary vasculature

up right-sided heart pressure

Right sided heart hypertrophy

right-sided heart failure.

heart sounds and auscultatory findings

mitral regurge Pansystolic Apex http://www.youtube.com/watch?v=MMJBSd5Z_Uc&feature=related

aortic stenosis Ejection systolic Aortic area and apex http://www.youtube.com/watch?v=Gbk2465HO98&feature=related

aortic regurge early diastolic Left sternal edge http://www.youtube.com/watch?v=42IahK-zxj0&feature=related

mitral stenosis Mid-diastolic Apex http://www.youtube.com/watch?v=L5DEqvgS_xs&feature=related

*remember grading of murmur*

MR.PS

ASES

ARED

MS.MD

http://www.med.ucla.edu/wilkes/inex.htm

http://filer.case.edu/dck3/heart/listen.html

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3.other inflammatory diseases

SLE

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4.ejection fraction

=SV/EDV

Pathophysiology of Heart Disease by Lily has normal Ejection Fraction = 55-75%. Damage to the muscle of the heart (myocardium), such as that sustained during myocardial infarction or in cardiomyopathy, impairs the heart's ability to eject blood and therefore reduces ejection fraction. This reduction in the ejection fraction can manifest itself clinically as heart failure.

The ejection fraction is one of the most important predictors of prognosis; those with significantly reduced ejection fractions typically have poorer prognoses. However, recent studies have indicated that a preserved ejection fraction does not mean freedom from risk

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5.assessment CF

Congestive heart failure (CHF) occurs when the heart can no longer meet the metabolic demands of the body at normal physiologic venous pressures. Typically, the heart can respond to increased demands by means of one of the following:

Increasing heart rate, which is controlled by neural and humoral input

Increasing contractility of the ventricles, secondary to both circulating catecholamines and autonomic input

Augmenting preload, medicated by constriction of the venous capacitance vessels and the renal preservation of intravascular volume

As the demands on the heart outstrip the normal range of physiologic compensatory mechanisms, signs of congestive heart failure occur.

These signs include

tachycardia;

venous congestion;

high catecholamine levels;

insufficient cardiac output with poor perfusion and end-organ compromise.

urine output - may need catherterisation to monitor output, plus fluid balance chart.

BP - may increased as heart is working too hard. Bed rest

Pulse - may be tachycardic for same reasons as above

oxygen saturation - will probably be low, need to apply O2 therapy, and get SPO2 monitor on.

Pain - morphine (opioids) will decrease pain but also cause respiratory depression.

ejection fraction