MCU College of Medicine
Laboratory Manual in Physiology
AY 2020-2021
MANILA CENTRAL UNIVERSITY
COLLEGE OF MEDICINE
DEPARTMENT OF PHYSIOLOGY
ACTIVITY #9: MIRACLE CURE
Members:
1. Rosales, Ma. Katrina C.
2. Samuel, Jeffrey Isaac
3. Sanchez, Christian Jewel M.
4. Sanchez, Isabella M.
5. Solana, Johannica Darryl D.
6. Varona, Jan Aur Ray L.
7. Vera Cruz, Aldyss Dhane B.
8. Vergara, Danielle Dominique M.
9. Villamero, Janina Marie A.
November 23, 2021
Learning Objectives:
At the end of these activities, the student will be able to: Discuss the
development of cardiac failure.
INTRODUCTION:
As the students read this excerpt from the novel “Miracle Cure” by Michael
Palmer, they will have to bring with them their knowledge on cardiac output,
venous return, and regulation. At the end of article, students will have a
better understanding of the topic in a clinical scenario.
Excerpt from “MIRACLE CURE”
Fiction Novel by:
Michael Palmer
It took every bit of her strength, but Sylvia Vitorelli managed to force a
third pillow under her back. She was nearly upright in bed now. Still she felt
queasy and hungry for more air. It was the dampness and the mold, she told
herself. If she were in her apartment in Boston rather than her son’s
farmhouse in rural upstate New York, this would not be happening. Not that
her breathing had been all that great in Boston, either. For months her
ankles had been badly puffed and her fingers swollen. And now, over the
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Laboratory Manual in Physiology
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past few weeks, she had been experiencing increasing trouble catching her
breath, especially when she lay down.
Sylvia cursed softly. She should never have agreed to make the trip
to Fulbrook. She should have told Ricky that she just wasn’t up to it. But
she really wanted to go. The ghost of her husband, Angelo, had made living
in their apartment a constant sadness. And the dust and noise surrounding
construction of Boston’s central-artery tunnel had made living in their part of
the North End unpleasant. Besides, her daughter-in-law, who had always
acted as if her visits were an inconvenience, had actually made the call
inviting her to spend almost two weeks away from the city. The kids ask for
you all the time Mama, she had said. And autumn is so beautiful up here.
Sylvia checked the time. Ricky, Stacey, and the children would be at
church for another half hour or so and then were going to stop by to see
some friends. She had begged off going with them, citing a headache. The
truth was, she didn’t feel as if she could even get dressed. She should try to
get up, maybe make something to eat, watch Mass on TV, but when she
tried to move, she suddenly was seized by a violent, racking spasm of
coughing, accompanied by a horrible liquid sound in her chest.
For the first time, she began to panic. The dreadful gurgling in her
lungs persisted. Now she was gasping for breath. Sweat began to pour off
her forehead, stinging her eyes. Her purse was right next to her on the
bedside table. She fumbled through it for her pills with no clear idea of what
she would do once she found them. Her fingers, which lately had remained
somewhat swollen most of the time, were now stiff, obscene sausages,
bluish and mottled.
The air in the musty room seemed heavy and thick. An extra fluid
diuretic pill might help. Maybe one of the nitroglycerin, too. Desperately, she
emptied her purse out onto the bed. Alongside several vials of pills was an
appointment card from the clinic at Boston Heart Institute. Drops of
perspiration fell from her face onto the ink. Her next appointment was a week
from tomorrow. In order to fly to Ricky’s for eleven days, she had had to skip
a Vascular treatment-the-first one she had missed in almost a year. But the
missed medication couldn’t possibly be the reason she was having so much
trouble breathing now. She was down to only one treatment every two
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weeks, and was due to drop to one a month before much longer. Besides,
her cardiologist had told her when she called that it was perfectly okay for
her to go.
Oh my God, she thought, as she frantically gulped down one pill from
each of the medication vials. Oh, my God, what’s happening to me?
Suddenly she remembered that the nitroglycerin, which she had not had to
take since the early days of her Vasclear treatment, was supposed to be
dissolved under her tongue, not swallowed. She tried to get a tablet into
place under her tongue, but her hands were shaking so hard that she spilled
the tiny pills all over the bed and onto the floor.
Her left ring finger was beginning to throb. The gold band she had
worn for over fifty years was completely buried in her flesh. The finger itself
looked terribly swollen and dark violet, almost black in color. Oh, please
God, help me…help me!
Drowning now, she struggled to force air through the bubbling in her
chest. A boring, squeezing pain had begun to mushroom outward from
beneath her breastbone and up into her neck- Angina, just like before she
had begun the treatments. She had to get Ricky on the phone. Or was it
better to call 911? She had to do something. Her nightgown was soaked
with sweat. She was breathing and coughing at the same time, getting
precious little air into her lungs. There was no telephone in the guest room.
Gamely, she pushed herself off the side of the bed and lurched across
to the bureau. Her feet were like water bottles, her toes little more than nubs
above the swelling. Another spasm of coughing took away what little breath
remained. She clutched the corner of the bureau, barely able to keep herself
upright. The cough was merciless now, unremitting. Perspiration was
cascading off her. Her head came up just enough for her to see that the
mirror was spattered with blood. Behind the scarlet spray was her ashen
face. She was a terrifying apparition. Her hair was matted with sweat.
Bloody froth covered her lips and chin.
Seized by fear unlike any she had ever known, Sylvia turned away
from her reflection, stumbled, and fell heavily to the floor. As she hit, she
heard as much as felt the snapping of the bone in her left hip. Sudden,
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blinding pain exploded from that spot. Her consciousness wavered, then
started to fade. The agony in her hip and chest began to let up.
Ricky…Barbara…Maria…Johnny…One by one her children’s faces flashed
through her thoughts. The last face she saw was Angelo's. He was smiling
…beckoning to her.
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MCU College of Medicine
Laboratory Manual in Physiology
AY 2020-2021
MANILA CENTRAL UNIVERSITY
COLLEGE OF MEDICINE
DEPARTMENT OF PHYSIOLOGY
ACTIVITY #9: MIRACLE CURE
Salient Features:
●
●
●
●
●
●
●
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Patient Sylvia Vitorelli, female
a feeling of suffocating or drowning that worsens when lying down
Productive cough - violent cough with blood, and with bubbling sounds
Dyspnea
Edema, Cyanosis - Dark violet, almost black in color swollen fingers
stiff, obscene sausages, bluish and mottled
Angina
soaked with sweat
Definition of Terms:
● Angina
○ It is also called angina pectoris which is a severe chest pain
characterized by squeezing.
● Edema
○ It is the abnormal accumulation of interstitial fluid in certain
tissues of the body which may manifest with swelling of the
extremities or with accumulation of fluid in the lungs and body
cavities.
● Nitroglycerin
○ It is a nitrate vasodilator used to treat or prevent angina,
hypertension, control heart failure in patients with myocardial
infarction, and to induce hypotension intraoperatively.
● Diuretics
○ also referred to as “water pills” - helps the body excrete salt
(sodium) and water in the form of urine
● Congestive heart failure
○ It is a disease that can be caused by a variety of abnormalities,
including pressure and volume overload, loss of muscle,
primary muscle disease or excessive peripheral demands such
as high output failure.
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Laboratory Manual in Physiology
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QUESTIONS:
1. Sylvia is having difficulty breathing so she placed a 3rd pillow
under her back.
○ How can this help her? (1 point)
■ Due to Sylvia having a difficulty in breathing she placed
a pillow under her back to elevate her position so that
the blood flows helps her body and airways to relax,
making breathing easier
■ When a person has a heart failure, the heart may not be
able to keep up with the increased amount of blood
returning to the heart, so fluid builds up inside the lungs
which causes shortness of breath.
○ What is the medical term for this? (1 point)
■ Orthopnea comes from the Greek words “ortho” meaning
“vertical” and “pnea” which means “to breathe”, is a type of
dyspnea that is usually a symptom of heart failure
characterized by sensation of tightening of the chest that
results in difficulty in breathing and some may also
experience chest pain that occurs in supine position but is
resolved when sitting or in standing position.
■ Dyspnea is the medical term for experiencing shortness in
breath often described as chest tightness, having difficulty in
breathing, feeling of suffocation, and hunger for air.
2. Her ankles and fingers are swollen for months. What conditions
can bring about this manifestation? Explain. (2 points)
○ The swelling of her ankles and fingers is called edema
because of the excess fluid trapped in the body’s tissues. If
there is a heart failure, it can cause both peripheral edema and
abdominal edema, in Sylvia’s case it is peripheral edema. The
heart loses the ability to pump blood efficiently so what
happens is that the blood piles up in front of the heart, as a
result the blood pressure increases in the veins causing the
fluid to leak outside into the surrounding tissue.
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Laboratory Manual in Physiology
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○ Edema in heart failures such as congestive heart failure is the
result of the activation of a series of humoral and
neurohumoral mechanisms that promote sodium and water
reabsorption by the kidneys and expansion of the extracellular
fluid.
3. She experienced a violent, racking spasm of coughing with
gurgling sound in her chest. What is happening now?(1 point)
○ Sylvia is experiencing pleural effusion also called “water on
lungs”, that results from abnormal increase of interstitial fluid
on her lungs due to elevated pulmonary capillary pressure.
○ Or in another instance, the patient might have pulmonary
edema which may have caused the crackling sounds in the
lungs. People with congestive heart failure (CHF) often have
pulmonary edema
○ It is. CHF occurs when the heart cannot pump blood
effectively. This results in a backup of blood, which increases
blood pressure and causes fluid to collect in the air sacs in the
lungs.
4. Her fingers aside from being swollen, now are swollen, now are
“stiff, obscene sausages, bluish and mottled”. What accounted
for the discoloration? (2 points)
○ Her symptoms are an indication of Cyanosis. It can be caused
by an insufficient supply or inadequate delivery to some parts
of the body. Since it occurs on Sylvia’s fingers, it is referred to
as Peripheral Cyanosis.
○ Cyanosis is a symptom of some instances or some underlying
conditions such as:
■ Reduced cardiac output secondary to heart failure or
shock
■ Local vasoconstriction due to cold exposure,
hypothermia, acrocyanosis, and Raynaud phenomenon
■ Vasomotor instability
■ Arterial obstruction causing regional ischemia
secondary to peripheral vascular disease. Causes
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Laboratory Manual in Physiology
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include
atherosclerosis,
Buerger
disease,
atheroembolism
■ Venous stasis or obstruction, such as in deep vein
thrombosis
■ Hyperviscosity attributable to multiple myelomas,
polycythemia, and macroglobulinemia
5. Angina was described as “boring, squeezing pain from beneath
the breastbone up into her neck”.
○ What is happening to her now? (1 point)
■ She is having an angina event wherein her heart works
hard to the point where pressure or squeezing pain
happens in the chest, up to the neck, arms, jaw, or even
the back, just like a heart attack.
■ Tight, gripping or squeezing that can vary from mild to
severe chest pain might be experiencing symptoms
similar to a heart attack. Angina happens when arteries
that carry the blood to the heart become narrowed and
blocked. Narrowing may be caused by atherosclerosis
of blood clot in the artery.
○ Why did the pain reach the neck? (1 point)
■ The arteries that are supplying oxygen-rich blood to the
heart are occluded which results in angina. Having a
depleted oxygen supply will result in anaerobic
metabolism in the myocardial cells producing lactic acid.
Lactic acid is also believed to be causing pain in the
heart that results in stimulation of pain receptors that
innervate the heart which are the afferent pathways that
is being carried by the multiple nerve roots from C7
through T4. The radiating pain of angina pectoris is
believed to occur because these afferent pathways also
carry pain fibers from other regions including the arm,
neck, and shoulders.
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Laboratory Manual in Physiology
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■ Also, during a heart attack, the diaphragm (since it is
proximal/close to the heart) and nearby accessory
nerve can become irritated causing pain to refer
elsewhere including the neck and shoulders.
6. What is the role of diuretics and nitroglycerin in her case? (1
point)
○ Diuretics are an integral part of heart failure treatment, along
with other medications to treat the underlying cause of heart
failure. Diuretics help the kidneys flush out the excess fluid
and maintain normal blood volume. It works by increasing the
urine output by inhibiting the reabsorption of sodium at
different segments of the renal tubular system
○ Nitroglycerin has the ability to reduce preload and afterload of
the heart muscle. It is a nitrate vasodilator used to treat or
prevent angina, treat hypertension, control heart failure in
myocardial infarction. It is taken sublingually that helps in
widening or dilation of coronary arteries to allow more
oxygen-rich blood to flow in the heart. It also works by relaxing
the smooth muscle and blood vessels in your body.
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Laboratory Manual in Physiology
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7. Create a concept map to explain the physiology
interrelatedness of the symptoms of Sylvia. (20 points)
and
Figure 1: Concept Map of the Symptoms of Sylvia
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MCU College of Medicine
Laboratory Manual in Physiology
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References:
● Cowled P, Fitridge R. Pathophysiology of Reperfusion Injury. In: Fitridge R,
Thompson M, editors. Mechanisms of Vascular Disease: A Reference
Book for Vascular Specialists [Internet]. Adelaide (AU): University of
Adelaide Press; 2011. 18. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK534267/
● Heart Failure | NHLBI, NIH. (2021, November 10). NHLBI.
https://www.nhlbi.nih.gov/health-topics/heart-failure
● Watson, S. (2018, September 18). Orthopnea. Healthline.
https://www.healthline.com/health/orthopnea
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