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).

Patients 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 37C; HR: 110/min; R: 25/min (tachypnea); sitting BP: 105/70
Head & neck: normal
Lungs: Late inspiratory crackles heard throughout both lung fields.
rd
Heart: 3 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 patients 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?