Emma, a 74-year-old woman with a history of rheumatic feverwhile in her twenties, presented to her physician with complaintsof increasing shortness of breath (\"dyspnea\") upon exertion. Shealso noted that the typical swelling she's had in her ankles foryears has started to get worse over the past two months, making itespecially difficult to get her shoes on toward the end of the day.In the past week, she's had a decreased appetite, some nausea andvomiting, and tenderness in the right upper quadrant of theabdomen.On physical examination, Emma's jugular veins werenoticeably distended. Auscultation of the heart revealed alow-pitched, rumbling systolic murmur, heard best over the leftupper sternal border. In addition, she had an extra, \"S3\" heartsound. A chest X-ray reveals a normal cardiac silhouette that isnormal in diameter, but her physical examination revealshepatomegaly and ascites, as well as pitting edema in her ankles.She is advised to wear support stockings and given a prescriptionfor digoxin. Two weeks later she returns to the office for afollow-up visit; upon physical examination, she still hassignificant hepatomegaly and pitting edema, and is significantlyhypertensive (i.e. she has high blood pressure). Her physicianprescribes a diuretic called furosemide (or \"Lasix\").
1. What is meant by the terms “hepatomegaly†and “ascites†andwhy are they happening? Why are her jugular veins distended? Bespecific in terms of blood pressure and Starling forces.
2. What is pitting edema and what is causing it?
3. Why is she advised to wear support stockings? If she hadatherosclerosis or blockage of a femoral artery, would this be anadvisable diagnosis? Why or why not?
4. Is the stress being placed on Emma's heart pre-load orafter-load and why?
