U Assessment

HISTORY. A history of rheumatic fever suggests possible cardiac valvular malfunction; however, many patients who have had rheumatic fever do not remember having the condition. The most common symptom of AI is labored breathing on exertion, which may be present for many years before progressive symptoms develop. Angina with exertion, orthopnea, and paroxysmal nocturnal dyspnea are also principal complaints. Patients with severe AI often complain of an uncomfortable awareness of their heartbeat (palpitations), especially when lying down.

PHYSICAL EXAMINATION. Inspection of the thoracic wall may reveal a thrusting apical pulsation. Palpation of the precordium reveals the apical pulse to be bounding and displaced to the left. Auscultation of heart sounds reveals the classic decrescendo diastolic murmur. The duration of the murmur correlates with the severity of the regurgitation. Auscultation of breath sounds may reveal fine crackles (rales) if pulmonary congestion is present from left-sided heart failure. The pulmonary congestion will vary with the amount of exertion, the degree of recumbency, and the severity of regurgitation. Assessment of vital signs reveals a widened pulse pressure caused by the low diastolic blood pressure (often close to 40 mm Hg). The heart rate may be elevated, in an attempt to increase the cardiac output and decrease the diastolic period of backflow.

PSYCHOSOCIAL. The symptoms of AI usually develop gradually. Most people have already made adjustments in their lifestyle to adapt, not seeking treatment until the symptoms become debilitating. Assess what the patient has already done to cope with this condition.

Diagnostic Highlights

Test

Normal Result

Abnormality with Condition

Explanation

Cardiac catheterization and aortic angiography

Doppler echocar-diography

Normal aortic valve Normal aortic valve

Diastolic regurgitant flow from the aorta into the left ventricle; increased left ventricular end-diastolic volume/pressure

Incompetent aortic valve

Aortic valve is incompetent and during diastolic phase, blood flows backward into the left ventricle

Aortic valve is incompetent and during diastolic phase, blood flows backward into the left ventricle

Other Tests: Echocardiography to assess aortic valves structure and mobility electrocardiogram (ECG); chest radiography, magnetic resonance imaging.

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