PHYSIO CASE PRESENTATION

(GROUP C-6)

• SOTELO
• SIMANGAN
• PULIDO
• PAMITTAN
• UDAUNDO
• SANGRAM

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 CASE 3

A 62 year-old woman with a history of atrial fibrillation presents to her primary care
physician with worsening shortness of breath when she lies down flat in the supine
position. She often has to sleep with several pillows at night and has frequent
urination at night (nocturia). She has noticed that her ankles are more swollen than
usual. Of note, she has run out of digoxin, which she takes to control her heart rate.
On examination, she is noted to be slightly hypotensive with blood pressure of 90/65
mm Hg. Her heart rate is 120 beats per minute and is irregularly irregular, consistent
with atrial fibrillation. She has bilateral pulmonary rales and increased jugular venous
distention. Her heartbeat is irregularly irregular without a murmur. No S3 or S4 is
noted. She has 3(+)(out of 4)-dependent peripheral edema of the legs. She is admitted
to the hospital for further management.

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 PATIENT’S PROFILE

•FEMALE
•62 YEARS OLD

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 CHIEF COMPLAINT

•WORSENING SHORTNESS OF
BREATH WHEN SHE LIES DOWN IN
FLAT IN THE SUPINE POSITION

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 HISTORY

• SHE OFTEN HAS TO SLEEP WITH

SEVERAL PILLOWS AT NIGHT AND HAS
FREQUENT URINATION AT NIGHT
(NOCTURIA).
• HER ANKLES ARE MORE SWOLLEN
THAN USUAL.
• SHE’S BEEN TAKING DIGOXIN TO
CONTROL HER HEART RATE.

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 PHYSICAL EXAMINATION RESULTS:

• BP = 90/65 (Slightly Hypotensive)

• Heart rate is 120 bpm is irregularly irregular, consistent with atrial fibrillation
• Has bilateral pulmonary rales and increased jugular venous distention
• Heartbeat is irregularly irregular without a murmur
• No S3 or S4 is noted
• Has 3(+) (out of 4)-dependent peripheral edema of the legs

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 DIFFERENTIAL DIAGNOSIS

•MYOCARDIAL INFARCTION
•CONGESTIVE HEART FAILURE
•CARDIOMYOPATHY

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 MYOCARDIAL CONGESTIVE HEART CARDIOMYOPATHY
INFARCTION FAILURE
FATIGUE Yes Yes Yes

PEDAL EDEMA Yes Yes Yes

DYSPNEA Yes Yes Yes

ORTHOPNEA Yes Yes Yes

RAPID OR FAST HEART RATE RAPID OR IRREGULAR HEARTBEATS THAT

IRREGULAR HEARTBEAT FEEL RAPID,
HEARTBEAT POUNDING OR
FLUTTERING
NOCTURIA No Yes No
RALES No Yes No
JUGULAR No Yes No
VENOUS
DISTENTION

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 MYOCARDIAL CONGESTIVE HEART CARDIOMYOPATHY
INFARCTION FAILURE
FATIGUE Yes Yes Yes

PEDAL EDEMA Yes Yes Yes

DYSPNEA Yes Yes Yes

ORTHOPNEA Yes Yes Yes

RAPID OR FAST HEART RATE RAPID OR IRREGULAR HEARTBEATS THAT

IRREGULAR HEARTBEAT FEEL RAPID,
HEARTBEAT POUNDING OR
FLUTTERING
NOCTURIA No Yes No
RALES No Yes No
JUGULAR No Yes No
VENOUS
DISTENTION

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 LEFT-SIDED/ SYSTOLIC HEART FAILURE

Signs/ Symptoms
• Dyspnea on Exertion
• Shortness of Breath
• Paroxysmal Nocturnal Dyspnea
• Orthopnea
• Dry, wheezing cough
• Exertional fatigue and weakness
• Exercise intolerance
• Nocturia
• Weight gain
• Cool extremities
• Diaphoresis

•Physical Findings
• Rales/ Crackles

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 RIGHT-SIDED / DIASTOLIC HEART
FAILURE

Signs/ Symptoms
• Tightness & Swelling (Edema)
• N/V
• Anorexia
• Abdominal pain
• Abdominal bloating (Ascites)

•Physical Findings
• Jugular Vein Distention

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 NO S3 OR S4

• If the LV is not overly compliant, as is in most adults, a S3

will not be loud enough to be auscultated.

Fourth heart sound: Filling of the ventricle by atrial systole

Reason this patient does not have an S4: She is is atrial
fibrillation and has NO ATRIAL CONTRACTION.

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 FINAL DIAGNOSIS

•CONGESTIVE HEART FAILURE

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 • Congestive heart failure (CHF) is a chronic progressive
condition that affects the pumping power of your heart
muscles. While often referred to simply as “heart
failure,” CHF specifically refers to the stage in which
fluid builds up around the heart and causes it to pump
inefficiently.
• You have four heart chambers. The upper half of your
heart has two atria, and the lower half of your heart has
two ventricles. The ventricles pump blood to your body’s
organs and tissues, and the atria receive blood from your
body as it circulates back from the rest of your body.

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 CHF develops when your ventricles can’t pump enough
blood volume to the body. Eventually, blood and other
fluids can back up inside your:
• lungs
• abdomen
• liver
• lower body

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 MANAGEMENT

WHEN ADMITTED:
• GIVE DIURETICS
• CONTROL HEART RATE
- stroke volume will decrease because of increased heart rate
- GIVE DRUGS THAT SLOW DOWN HEART RATE (digoxin, calcium
channel blocker, beta adrenergic blocker)
• GIVE BLOOD THINNER (PATIENT IS PRONE TO STROKE)

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 • IF THE HEART RATE IS ALREADY CONTROLLED AND YET THE PATIENT IS STILL
SYMPTOMATIC, THERE IS A NEED TO TERMINATE THE RHYTHM PROBLEM.

1. PHARMACOLOGIC CARDIOVERSION
- convert atrial fibrillation to normal sinus rhythm
If not converted,
2. ELECTRICAL CARDIOVERSION
- a process by which the heart is shocked to convert it from an irregular rhythm back into a
normal sinus rhythm.
- for patients in persistent atrial fibrillation, electrical cardioversion may be done early in the
process to stop the afib and put the heart back into normal sinus rhythm.

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