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Jalayna Rick, Eric Scrivner, Anne Sirany, Chris Steevens, Nick Vidor

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History I have been really tired lately. Fatigue with activity, sleeping much more than normal Dyspnea with activity and at night 1 ppd smoker for 30 yrs, 2-3 beers per day FHx: brother with HTN, father died of MI at 48 Husband is chemical engineer phthalate esters Some anorexia, but weight gain of 10 lbs. Irregular menses, hot flashes at night Anxiety at times that is helped by alcohol Hx of ALL at age 8

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Lets Get Physical

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Physical Exam Findings Adult female, looks comfortable at rest, mildly anxious BP 100/70, HR 80, RR 16 Lungs clear with occasional crackles at right base S1 S2 normal, S3 at apex Grade III/IV holosystolic murmur at apex with radiation to axilla Neck veins noted to mid-neck at 30 degree elevation of head with positive abdominaljugular reflux Liver percussed 3cm below costal margin, total span of 16cm Intact pulses in extremities, 2+ edema Mild tremor

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Class Differential Dx?

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Our Differential Dx Pneumonia Phthalate toxicity Leukemia Tx complications or relapse Lung cancer Thyroid problem Endocarditis Pulmonary embolism Valvular disease (mitral regurgitation) causing CHF

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Pneumonia Corresponding S & Sx: Dyspnea Crackles Fatigue Nightly hot flashes (night sweats) Inconsistencies Normal CBC ($41) Afebrile

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Phthalate Toxicity Corresponding S & Sx: Weight gain Lung infection/involvement Hepatomegaly Inconsistencies: Poorly absorbed through the skin Mostly problematic in children Low exposure levels (secondary, skin exposure)

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Leukemia Relapse Corresponding S & Sx Past Hx Dyspnea Fatigue Menstrual irregularities Night hot flashes Unexplained weight changes Hepatomegaly Inconsistencies CBC normal No lymphadenopathy

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Lung Cancer Corresponding S & Sx Smoker Progressive dyspnea Progressive fatigue Pulmonary HTN would be consistent with her HF symptoms Holosystolic murmur pulmonary HTN (tricuspid) Inconsistencies Normal CBC CXR ($131) no lung masses observed

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Thyroid Problem Hypothyroidism Correlating: middle-aged woman, unexplained fatigue and weight gain individuals with hypothyroid are twice as likely to develop CHF Test: Thyroid study (free!) T3: 34.9% T4: 69.1 nmol/L TSH ($58): 1.2 m IU/mL (normal)

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Endocarditis Correlating factors: Fatigue New heart murmur SOB Night sweats Edema in extremities Predisposing factors: Therapeutic immunosuppression from chemotherapy Inconsistencies No fever or chills No weight loss actually weight gain Absence of classic signs Janeway lesions Roth spots Osler nodes Normal blood culture ($76) and CBC

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Pulmonary Embolus Corresponding S & Sx Dyspnea Smoker Crackles auscultated Extremity Edema Inconsistencies No chest pain Dyspnea was not acute Murmur characteristic to left side of heart

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PE Rule Out CXR D-dimer CT PE Study if positive D-dimer

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Congestive Heart Failure Correlating factors: 2+ pitting edema in extremities crackles in right base SOB paroxysmal nocturnal dyspnea, Fatigue weight gain FHx of heart disease enlarged liver with positive HJR JVD to mid-neck

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Labs to Dx CHF CXR ($131) EKG ($78) Echo ($540) BNP (not an option for us)

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Chest X-ray read by local experts: Is it a good picture? Cardiac Enlargement: heart shadow is greater than of transthorasic area Pleural Cavity fluid: clear costophrenic angles, so no Pulmonary Infiltrate: possible infiltrate on the right side Chest X-ray read by local experts: Is it a good picture? Cardiac Enlargement: heart shadow is greater than of transthorasic area Pleural Cavity fluid: clear costophrenic angles, so no Pulmonary Infiltrate: possible infiltrate on the left side

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ECG Read by the Experts: SIRAH PBBII S=Standard calibration, Intervals: (PR~120ms, QRS~80ms, QT~360ms), Rate:~ 65, Axis: positive on lead I and aVF=normal (0-90deg), Hypertrophy: SV1RV5