tailieunhanh - Heart Disease in Pregnancy - part 8

Các dấu hiệu thực thể thường giả vài. Dấu hiệu lâm sàng của suy thất phải cấp tính có thể được tinh tế. Thở nhanh là thường xuyên theo sau bởi nhịp tim nhanh. Áp lực tĩnh mạch tinh mạch cảnh có thể được nâng lên và có thể được tăng lên parasternal đập trái tim | Pulmonary embolism 249 Physical signs are often deceptively few. Clinical signs of acute right ventricular failure can be subtle. Tachypnea is the most frequent followed by tachycardia. The jugular venous pressure may be raised and there may be increased left parasternal pulsation a third heart sound gallop and widely split second sound. The lungs are usually clear but there may be focal crackles as surfactant is lost from non-perfused segments of lung. At this stage the arrival of further emboli will very probably be fatal but otherwise the evidence of acute cor pulmonale has usually resolved in just a day or two. Massive PE The patient who may have seemed quite fit up to then has suddenly collapsed and is in shock pale cold clammy and shut down or in actual circulatory arrest. In patients with maintained consciousness tachypnea and hyperpnea are striking with poor peripheral perfusion. Substernal chest pain may be confusing. The lungs are usually clear with good air entry. Rarely PE may trigger bronchospasm in people with asthma. The pulse is rapid and ill-sustained and blood pressure maintained only with the patient supine. There may be pulsus paradoxus as filling of the left ventricle and stroke volume fall on inspiration see Figure . The venous pressure will be raised but this cannot be observed clinically because the patient is lying flat and also because of her heightened respiratory efforts. A third heart sound gallop is prominent but pulmonary valve closure is soft not accentuated as generally stated and may be absent if the right ventricular diastolic pressure has risen to equal the diastolic pressure in the pulmonary artery. In less severe cases the second heart sound is widely split. A systolic murmur of tricuspid regurgitation may be audible but it is often silent because right ventricular pressure and flow may be insufficient to produce audible turbulence and indeed all the heart sounds become soft as the circulation fails. When circulatory .