Duncan I: Short of Breath

Cardiovascular System


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M32_F1.jpg"}},{"insert":"\n\nAs you slip on your white coat, you marvel at the contrast between your natural manner at the clinic and the awkwardness that takes over when it comes to routine social interactions.\n\nCringing at the memory of last night\u0027s date, you\u0027re relieved when the door swings open, delivering the first patient of the day into your office.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M32_F3.jpg"}},{"insert":"\n\nYou are introduced to 56-year-old Duncan, who is visiting your clinic for the first time.\n\nDuncan complains of painless progressive swelling of both legs for the last 6 months. He has also felt increasingly tired and \u0022without energy\u0022 for the last 3 months. For the past 1 month, he has been waking up at night over and over again, feeling breathless.\n\nYou look at Duncan\u0027s medical records. He experienced an inferior ST-elevation myocardial infarction (STEMI) 12 months ago, which was treated with percutaneous coronary intervention (PCI) and stent placement. He was also found to be hypertensive and dyslipidemic at that time. On discharge, he was started on nitroglycerin, atenolol, aspirin, valsartan, and lovastatin. He defaulted on follow-up after just 3 months and stopped taking his medications shortly afterwards.\n"}]}


{"ops":[{"insert":"You ask Duncan if he feels breathless when exercising. He responds that he doesn\u0027t really exercise, but that he does feel breathless after walking several blocks, or if he tries to walk briskly. You ask if he feels breathless when performing his activities of daily living, to which he responds in the negative.\n\nYou also ask Duncan if he\u0027s experienced any chest pain or discomfort, or any other symptoms at all \u2013 no matter how small. After some thought, he says \u0022no\u0022.\n\nInquiring about his family and social history, you find out that Duncan\u0027s father died of a \u0022heart attack\u0022 at age 60. His family history is unremarkable otherwise. Duncan smoked for a short time in his early youth, but stopped afterwards. He only drinks socially. He is divorced and lives alone. He has one adult child, a son who lives on the opposite side of the country.\n\nYou gently ask why he suddenly stopped going to his old cardiology clinic. He looks vaguely embarrassed and mumbles, \u0022well, my insurance co-pay was just too much, doctor.\u0022\n\nYou feel grim. This is a sad story you\u0027ve heard just too many times.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M32_F7.jpg"}},{"insert":"\n\nYou ask Duncan for permission to examine him, which he grants. His temperature is 98.4\u02daF (36.9\u02daC), pulse is 100 bpm and regular, blood pressure is 140\/90 mmHg, and respiratory rate is 24\/min. The jugular venous column extends all the way up into the mastoid process. You also note bilateral pitting edema up to the mid calves.\n\nDuring the cardiorespiratory examination, you note that the the cardiac apex beat is displaced to the left sixth intercostal space, in the anterior axillary line. On auscultation, you hear the fourth heart sound. Bibasal crackles are audible. The remainder of the systems examination is unremarkable.\n"}]}


{"ops":[{"insert":"You worry that Duncan may have developed heart failure. You decide to order an ECG, chest x-ray and echocardiogram. You also order a basic blood panel as well.\n\nWhat else will you order?\n"}]}
1. Nothing else
2. Brain natriuretic peptide (BNP) levels
3. Cardiac enzymes