ASSESSMENT OF CARDIOVASCULAR SYSTEM

A 67-year-old Mexican-American woman is admitted to the hospital for dyspnea and progressive fatigue. The patients history reveals that she is 45 lbs overweight from her previously recorded weight one year ago. She has had insulin-dependent diabetes for 23 years that is controlled with daily insulin. A 24-hour account by the patient of her diet reveals an intake of high-sodium and highcholesterol foods. Her exercise routine includes walking a half-mile for 20 minutes 1 to 2 times a week. She states she smokes one pack per day and has done so for 40 years. She reports no alcohol consumption. At night she sleeps with three pillows and gets up urgently to void at least once each night. The patient is slightly dyspneic while speaking one to two sentences and then must stop to rest for 2 minutes before she can resume answering questions. On assessment she has anasarca and ascites. Jugular vein distension is 4 mm above the sternal angle with the head of bed elevated at 45 degrees. A right ventricular heave is observed at the sternal border with the patient in a semiFowlers position. Her skin is pale and cool to the touch. Her apical pulse is not palpable. Radial pulses are 1+ bilaterally and pedal pulses are 1+ bilaterally on palpation. Auscultation of the heart reveals S1, S2, and S3. She denies any chest pain

Vital signs are: pulse oximeter reading 90%, but after administering 2 L of oxygen per nasal cannula the pulse oximeter reading elevates to 93%; temp 36.3 C (97.3F); heart rate and rhythm 88/min, sinus arrhythmia with occasional PVCs; respirations 28/min.

QUESTIONS:
1. Document the case study above using the format of 1) history, 2) inspection, 3) palpation, 4) auscultation, and 5) additional notes. 2. What kind of heart failure (which side) does this patients assessment reveal? 3. What does the auscultation of S3 indicate? 4. The patient reports that she sleeps on three pillows at night. What does this indicate?

CASE STUDY
History
The patients history reveals that she is 45 lbs overweight from her previously recorded weight one year ago. She has had insulin-dependent diabetes for 23 years that is controlled with daily insulin. A 24-hour account by the patient of her diet reveals an intake of high-sodium and highcholesterol foods. Her exercise routine includes walking a half-mile for 20 minutes 1 to 2 times a week. She states she smokes one pack per day and has done so for 40 years. She reports no alcohol consumption. At night she sleeps with three pillows and gets up urgently to void at least once each night.

Inspection
The patient is slightly dyspneic while speaking one to two sentences and then must stop to rest for 2 minutes before she can resume answering questions. On assessment she has anasarca and ascites. Jugular vein distension is 4 mm above the sternal angle with the head of bed elevated at 45 degrees. A right ventricular heave is observed at the sternal border with the patient in a semiFowlers position.

Palpation
Her skin is pale and cool to the touch. Her apical pulse is not palpable. Radial pulses are 1+ bilaterally and pedal pulses are 1+ bilaterally on palpation.

Auscultation
Auscultation of the heart reveals S1, S2, and S3. She denies any chest pain

Additional Notes
Vital signs are: pulse oximeter reading 90%, but after administering 2 L of oxygen per nasal cannula the pulse oximeter reading elevates to 93%; temp 36.3 C (97.3F); heart rate and rhythm 88/min, sinus arrhythmia with occasional PVCs; respirations 28/min.

2. In adults, the third heart sound is a physical sign specific for left ventricular failure. It is
heard predominantly in dilated hypocontractile left ventricles, but may also be heard in the setting of severe mitral regurgitation. In left ventricular failure, the origin of the third heart sound is thought to be the sudden cessation of early, rapid left ventricular filling impelled by high left atrial pressure. 3. The S3 indicates an enlargement ventricular chamber 4. This indicates that the patient needs to elevate her head to promote adequate ventilation.