Sketchy Path: Congestive Heart Failure Clinical Manifestations

Question 1

What will histologic exam of the lungs of someone with left-heart failure show?

Answer 1

• Foamy pink transudate (like the pink foam beneath the boat)
• Hemosiderin-laden macrophages (like the cages by the pink foam)

Question 2

Pulmonary edema is a symptom of _____________.

Answer 2

left-heart failure (like the guy on the boat with the wet life preserver)

Question 3

Why do those with left-heart failure get dyspnea?

Answer 3

The fluid back up in the lungs leads to decreased compliance (like the girl with the tight corset who can’t breathe)

Question 4

What nerves sense the fluid retention in the lungs?

Answer 4

C fibers (like the C-shaped hook that the girl who can’t breathe has snagged the swimmer with)

Question 5

_______________ is a specific sign of left-heart failure.

Answer 5

Orthopnea (like the guy falling backward in the boat with a wet life preserver)

This occurs because venous blood pools when standing and then rapidly returns to the heart upon lying down. Because the left heart can’t clear it fast enough, the fluid pools in the lungs.

Question 6

What lung sounds will you hear in a patient with left-sided heart failure?

Answer 6

Bibasilar crackles (like the swimmer with the two-pronged snorkel that’s bubbling from both sides)

Question 7

When sleeping, patients with left-sided heart failure will often get _______________.

Answer 7

paroxysmal nocturnal dyspnea (like the guy sleeping in the storm drain with several pillows)

Question 8

What is cardiac asthma?

Answer 8

Excessive pulmonary congestion from left-sided heart failure can press on the bronchioles and lead to airway narrowing. This can even lead to wheezing! It’s totally different than regular asthma, though.

(Think of the guy blowing the party whistle into the storm drain.)

Question 9

What x-ray signs are suggestive of congestive heart failure?

Answer 9

• Congestion of the pulmonary arteries (like the thick white mast branches over the pirate ship)
• Fluffy white infiltrate where fluid has leaked into the alveoli (like the fog over the ship’s sail)
• Kerley B lines (like the curly B on the hotel)
• Cardiomegaly (like the big heart)
• Radiolucent airways (like the first mate’s shadow)

This is often referred to as the bilateral bat-wing sign.

Question 10

What are Kerley B lines?

Answer 10

Fluid accumulation between the lobes (like the black bands on the sail)

Question 11

Why do the airways appear more lucent in x-rays of those with left-heart failure?

Answer 11

More fluid accumulates in the interstitium and makes the parenchyma of the lung more opaque. Thus, the airways seem more lucent by comparison.

(Think of the shadow of the first mate cast onto the sail.)

Question 12

What are the word mnemonics for S3 and S4?

Answer 12

S3: “slosh ing-in” (like the king’s slushie)
S4: “a-stiff wall” (like the stiff-waled chair)

Question 13

What valvular complication car arise in the setting of left-heart failure?

Answer 13

Mitral regurgitation due to left-atrial dilation

Think of the mitral jester regurgitating wine all over the dilated balloon.

Question 14

Why do the pulmonary vessels constrict in left-sided heart failure?

Answer 14

The congestion damages the endothelial walls which decreases the release of NO and increases the release of endothelin.

(Think of the guy in the boat with the damaged NO engine wringing out his red shirt.)

Question 15

What does persistent pulmonary hypertension – such as that from left-sided heart failure –do to the vessels?

Answer 15

It causes collagen deposition and smooth muscle hypertrophy in the media (like the collagen shark tattoo on the smooth muscular physique of the guy in the boat).

Question 16

Persistent pulmonary hypertension from left-sided failure can lead to ___________ failure.

Answer 16

right-sided (like the fish pulling on the right side of the coral beneath the pulmonary hypertension guy)

Question 17

Right-sided heart failure from a lung pathology is called ____________.

Answer 17

cor pulmonale (like the CORk in the bottle between the left and right scenes)

This can be caused by clots (like the cucumber clots and the saddle on the seahorse).

Question 18

What valvular complication car arise in the setting of right-heart failure?

Answer 18

Tricuspid regurgitation (

Question 19

What physical exam signs suggest right-heart failure?

Answer 19

• Tricuspid regurgitation (holosystolic murmur over left lower sternal border)
• JVD (like the blue jugs on the table)
• Hepato-jugular reflex –when pressure on the LUQ elicits JVD (like the waiter carrying liver knocking over the jug)
• Kussmaul sign –when JVD increases during inspiration instead of decreasing like it should (like the guy smelling the COOkie SMeLl near the jugs)
• Peripheral edema (like the little mermaid’s swollen pants)
• Painful hepatomegaly (like the crying manatee with the liver spot)

Question 20

Histologically, people with ___________ will have congested, “nutmeg” livers.

Answer 20

right-heart failure (like the liver on the table by the jugs)

Question 21

Which part of the liver is damaged in right-heart failure?

Answer 21

Centrilobular (zone 3)

Think of the “course III” sign.

Question 22

If the liver congestion gets bad enough, _____________ can result.

Answer 22

portal hypertension and ascites (like the cracked porthole and the boy with the pool floatie)