Ace the Case: A 53-Year-Old Woman with Shortness of Breath on Exertion

Case Presentation

Chief Complaint: Shortness of breath

History of Present Illness: Ms. R is a 53-year-old woman who presents to her primary care physician with complaints of shortness of breath with exertion. She states she becomes winded climbing one flight of stairs, which was previously not a problem for her. She also reports some intermittent chest pain. She has been using her albuterol inhaler when she feels short of breath but states it is not helping.

Past Medical History: Mild intermittent asthma, chronic hypertension (well-controlled), and hypercholesterolemia

Medications: Albuterol inhaler less than once per week; hydrochlorothiazide 25 mg daily; multi-vitamin daily

Physical Examination: Vital signs are stable (blood pressure and heart rate are normal). Heart rate is regular and rhythm and lungs are clear without wheezing. Her abdomen is soft, nontender, and non-distended. Extremities show trace edema bilaterally.

Labs: Complete blood count and chemistry are normal

Electrocardiogram: Normal sinus rhythm

Chest radiography: Central pulmonary arterial dilation

Echocardiogram: Significant for an elevated peak tricuspid regurgitation (3 m/s), pulmonary artery diameter of >25 mm, and inferior cava diameter of >21 mm with decreased inspiratory collapse; normal ejection fraction (65%)

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Question
What is the best test to diagnose the patient’s condition?
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Correct answer: B.

Rationale: This patient has findings of pulmonary arterial hypertension (PAH), which is diagnosed with a right-heart catheterization.1 Any patient with a tricuspid regurgitation >2.9 m/s is at a high risk for pulmonary hypertension and should have right-heart catheterization performed.1 Other factors suggestive of pulmonary hypertension include an elevated right or left ventricular basal diameter ratio, flattening of the interventricular septum, decreased right ventricular outflow Doppler acceleration time, midsystolic notching, early diastolic pulmonary regurgitation velocity >2.2 m/s, pulmonary artery diameter >25 mm, inferior vena cava diameter >21 mm with decreased inspiratory collapse, and an end-systole right atrial area >18 cm2.1 Although 5 types of pulmonary hypertension exist, PAH is the most likely given the normal ejection fraction and the patient’s uncomplicated medical history.1

Although pulmonary function testing and arterial blood gas can suggest the diagnosis, they are not diagnostic.1

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