V. EXAMPLES AND ALGORITHM OF CASES' SOLUTION

N 93*

A 40-year-old patient Z. suffers from tuberculosis. He has come to see his physician with complaints of dyspnea, pains in the right upper quadrant, and subfebrile fever. These symptoms emerged four weeks ago and were progressing. On examination: the face is pale and rounded; orthopnea is evident (the patient is sitting upright with his hands resting upon chair, this posture is necessary to ease breathing); the area of cardiac dullness is increased to the left and to the right by 2 cm, heart rate is 100 per minute, blood pressure is 90/60 mm Hg. On auscultation: muffled heart sounds, crackles at the base of the lungs. Breathing rate is 26 per minute. The neck veins are distended; the liver is tender on palpation and extends 3 cm below the costal margin; there is trace pretibial and feet edema. An X-ray examination of the chest shows the globular shadow of the heart.

Questions

•  Does the patient have signs of cardiac insufficiency? Substantiate your answer.

•  What additional tests are required to specify the form of the heart pathology in this case?

•  Make a conclusion about the form of cardiac insufficiency in this patient.

Answers

•  The patient has cardiac insufficiency manifested by orthopnea, tachycardia, rales in the lungs, distention of the neck veins, enlargement of the liver, edema of the lower extremities.

•  Ultrasound investigation may show the presence of fluid in the pericardial cavity.

•  Total diastolic heart insufficiency caused by tuberculous pericarditis which complicates tuberculosis in this patient. Fluid in the pericardial cavity compresses the heart and disturbs filling of ventricles.