Physiology Clinical Case Mr. C.S.

ELECTROCARDIOGRAPHY
Personal Data:
Name: C.S.
Age: 66 year-old
Gender: Female
Occupation: Retired office worker

Patients complaint
Shortness of breath on exertion, chest pain and syncope

History of presenting complain

The patient refers that shortness of breath began about a year ago, but has becoming worst. Now
only with climbing one floor of stairs or walking one block the shortness of breath makes her stop.
Also she said that during the last week, besides the shortness of breath she is feeling pain on the
nd
chest that disappears when she rests. This morning she fainted after climbing to the 2 floor of her
house, and she was lucky because her niece was there and brought her to the ER. And at this time
the pain is not present.
She mentions that she knows she has certain heart problem but she hasnt visited her physician for
many years because she was filling well. And she does not remember what problem she has.

Past medical history

Cardiovascular: history of valve disease and murmur since 20 years ago. She doesnt provide more
information.
Past surgical history: tonsillectomy at age 16
Past psychiatric history: negative. Minor depression when her brother passed away
Past obstetric/gynecologic history: Menarche: 12 years of age.Regular period: 28x4
G:4, P:4 (A:0). Menopause at age 50
GI tract, urinary, skeletal muscle: negative
No DM
Medications: Statins, with irregular intake, Tylenol.
Allergies: negative

Family history
Father: Diseased. Diabetic
Mother: Diseased.
Brother: Heart infarction, at age 50

Social history
Smoking history: Positive. (1 pack/week)
Alcohol history: She considers herself as social drinker. (2-3 drinks during the weekends)
Recreational drug use or dependence: Negative

Physical Examination
VS: T 37C; R: 18/min; BP: 110/75
Head: normal
Neck: Palpation of the carotid upstroke reveals a pulse that is both decreased and late relative to the
apical impulse.
Lungs: clear and no rales.

Heart: systolic murmur, loudest over the aorta and peaking at mid systole. Palpation of the chest
reveals an apical impulse that is laterally displaced.
Abdomen: symmetric, soft, peristalsis is present.

Laboratory
Cardiac Enzymes (3 hours after the last episode of chest pain)
CK-MB: negative
Troponin I: negative
Myoglobin levels: normal
Plasma glucose 80 mg/dl (N: 80-100 mg/dl)
Hemoglobin: 14.3 g/dl (13-15 g/dl)
Htc: 39% (36-40 %)
No other information is provided.

Imagenology
Chest X-rays: Enlarged left ventricle and calcification of aortic valve
Doppler ultrasonography: Greatly increased velocity of flow during the systolic time of the cardiac
cycle. The left ventricle chamber is enlarged, and left ventricular hypertrophy is present.
Ventricular systolic pressure is about 180 mmHg. Enlargement of left atrium (lead II and V1)

EKG:

Discussion of the Case (Cardiac cycle)

1. What causes the murmur in the patient?

2. What is the chest location at which the murmur of the patient is best heard?
3. How do you distinguish this murmur from the one caused by Aortic
Regurgitation? Describe the function of the aortic valve
4. Draw the Wiggers diagram showing the LVP, Aortic P, and location of the
murmur.
5. What is the most likely underlying mechanism causing the patient to faint?
6. What is the cause of the diminished carotid pulse?
7. What is the most likely explanation of the chest pain?
8. How do you consider is the effective ejection fraction of the patient?