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Slide 1
Jalayna Rick, Eric Scrivner, Anne Sirany, Chris Steevens, Nick
Vidor
Slide 2
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
Slide 3
Lets Get Physical
Slide 4
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
Slide 5
Class Differential Dx?
Slide 6
Slide 7
Our Differential Dx Pneumonia Phthalate toxicity Leukemia Tx
complications or relapse Lung cancer Thyroid problem Endocarditis
Pulmonary embolism Valvular disease (mitral regurgitation) causing
CHF
Slide 8
Pneumonia Corresponding S & Sx: Dyspnea Crackles Fatigue
Nightly hot flashes (night sweats) Inconsistencies Normal CBC ($41)
Afebrile
Slide 9
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)
Slide 10
Leukemia Relapse Corresponding S & Sx Past Hx Dyspnea
Fatigue Menstrual irregularities Night hot flashes Unexplained
weight changes Hepatomegaly Inconsistencies CBC normal No
lymphadenopathy
Slide 11
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
Slide 12
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)
Slide 13
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
Slide 14
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
Slide 15
PE Rule Out CXR D-dimer CT PE Study if positive D-dimer
Slide 16
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
Slide 17
Labs to Dx CHF CXR ($131) EKG ($78) Echo ($540) BNP (not an
option for us)
Slide 18
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
Slide 19
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