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Additional findings usually include tachycardia

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Additional findings usually include tachycardia, diaphoresis,pallor, and peripheral cyanosis with pallor. Although edemais considered a classic finding in HF, a substantial gain ofextracellular fluid volume (i.e., a minimum of 5 L in adults)must occur before peripheral edema is manifested. As aresult of liver engorgement from elevated right-sided heartpressures, hepatojugular reflux, hepatic engorgement, andtenderness are typically noted. The point of maximal impulseis normally at the fifth intercostal space, mid-clavicularline. This shifts laterally and perhaps over more than oneintercostal space in the presence of dilated cardiomyopathyand its resultant increase in cardiac size.Patients with HF are often assigned a classification ofheart disease from the New York Heart Association (NYHA),where a relationship between symptoms and the amount ofeffort required for provocation is assessed. In treating anacute HF exacerbation, a patient often is initially consistentwith a higher classification category (NYHA III or IV). Aftertreatment, the assignment of lower category (NYHA I or II)is likely noted and should be a clinical goal.ECG helps to identify the presence of left atrial enlarge-ment, left ventricular hypertrophy, and dysrhythmias oftennoted in HF but not specific to the diagnosis. ECG changesconsistent with acute myocardial ischemia or MI as the causeof HF may also be revealed.Laboratory testing in HF usually includes evaluation torule in or rule out potential underlying causes (e.g., anemia,infection, renal insufficiency). B-type natriuretic peptide(BNP) is an amino acid structure common to all natriureticpeptides. The cardiac ventricles are the major source of plas-ma BNP; the amount in circulation is in proportion to ven-tricular volume expansion and pressure overload. As part ofthe evaluation of a patient with dyspnea and suspected HF,an elevated BNP level helps to support the diagnosis. Theincreased circulating volume found in HF can occasionallylead to evidence of hemodilution on hemogram; this cor-rects as circulating volume is normalized.Findings on chest radiograph in HF include car-diomegaly and alveolar edema with pleural effusions andbilateral infiltrates in a butterfly pattern. Additional findingsare loss of sharp definition of pulmonary vasculature, hazi-ness of hilar shadows, and thickening of interlobular septa,also known as Kerley B lines. As part of the evaluation ofheart valve function and competency, an echocardiogram isusually obtained. Radionuclide evaluation of left ventricularfunction provides helpful information on global heart func-tion. Angiography and further studies should be directed byclinical presentation and other health risks.The goal of HF therapy is threefold: reduction of preload,reduction of systemic vascular resistance (afterload reduc-tion), and inhibition of the renin and sympathetic nervoussystem. Because ACEIs and angiotensin receptor blockers(ARBs) cause central and peripheral vasodilation, thesemedications result in a reduction in cardiac workload andimprovement in cardiac output. Although ACEIs andARBs are the cornerstone of HF therapy, their use can beC H A P T E R 5Chest Disorders127

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Sexuality Now: Embracing Diversity
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Sexuality Now: Embracing Diversity
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