Zebra Hunters #1 Dyspnea

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!!The Zebra Hunter !!!!//Case #1// ---- ''History'' __Chief Complaint:__ A 54 year old male presents complaining of dyspnea for the last 7 days. Internal Medicine is consulted for evaluation. __History of Presenting Illness:__ The patient is an African American male who is being seen in the emergency department for complaints of dyspnea over the last 7 days. He describes progressive dyspnea for the last 7 days. In that week he has also had orthopnea, paroxysmal nocturnal dyspnea, bilateral leg swelling, weight gain, and a dry cough. He adds that he was recently diagnosed with congestive heart failure and is adherent to his diet restrictions. He takes his furosemide consistently but recently ran out and has been unable to get a refill. No recent fevers, chills, chest pain, sputum production, hemoptysis, nausea, vomiting, or palpitations. __Past Medical History:__ 1. HFpEF, newly diagnosed 3 months ago * LVEF 55-60% with Grade 1 Diastolic Dysfunction (per echo, 3 months ago) * [[See Transthoracic Echocardiogram (from 3 months prior)|echo]] * [[See Electrocardiogram (from 2 years prior)|EKG]] 2. Hyperlipidemia 3. Chronic Venous Insufficiency 4. Migraine Headaches 5. No history of hypertension or diabetes mellitus. __Home Medications:__ * Furosemide, 20 mg, daily [recently ran out] * Simvastatin, 20 mg, qHs __Surgical History:__ LE Venogram __Social History:__ No smoking history; abstains from alcohol and illicit drugs. Single. No sexual activity. __Family History:__ None; no known cardiac disease. __Allergies:__ NKDA __Review of Symptoms:__ No night sweats or weight loss; intermittent fatigue; intermittent sweats. No vision problems. No rhinorrhea, sore throat, ear drainage, tinnitus, hearing changes. Dyspnea; dry cough; no sputum, hemoptysis, wheezing, pleuritic pain. Bilateral leg swelling; no chest pain, palpitations, syncope. No diarrhea, abdominal pain, nausea, vomiting, constipation. No dysuria, hematuria, flank pain. No fevers. Chronic neck and back pain; no joint pain or swelling. No rashes or hives. No headache, numbness, seizures. No bleeding. No depression or anxiety. ---- ''Physical Exam'' __Vitals:__ BP 116/69, HR 90, RR 18, Temp 36.4 C (97.5 F), SpO2 100% on RA __General:__ Alert and Oriented x3. No acute distress. Appears comfortable. BMI 40. __HEENT:__ No pallour or icterus. Pupil equal. EOMI. Moist oral mucosa. No pharyngeal erythema. Hearing normal. Dilated neck veins and prominent jugular venous pulse. __Cardiovascular:__ Heart rate regular with audible S1 and S2. Persistent splitting of S2. No murmurs. Peripheral pulses palpable and symmetric. 3+ pitting edema bilaterally from the dorsum of the feet to the scrotum and lower abdominal quadrants. __Respiratory:__ Respirations non-laboured. No wheezing. Diminished breath sounds at the right lung base. Bilateral inspiratory crackles, worse on the right. __Gastrointestinal:__ Obese, soft, non-tender, non-distended. Bowel sounds present. __Neurological:__ Cranial nerves II to XII grossly intact. Motor and sensory systems symmetrical and intact. Reflexes difficulty to elicit. __Skin:__ Warm and intact. No notable erythema or obvious lesions. __Psychiatric:__ Cooperative, calm, pleasant. ---- The patient has already had some labwork completed (see below). __Chemistry__ Na 142 mmol/L (135-145) K 4.3 mmol/L (3.5-5) Cl 105 mmol/L (95-105) CO2 30 mmol/L (18-24) BUN 24 mg/dL (8-21) Cr 1.13 mg/dL (0.8-1.3) Mg 1.9 mEq/L (1.5-2) Ca 10.4 mg/dL (8.5-10) __Hematology__ Hgb 11.5 g/dL (13-17) Hct 33.4% (40-52) WBC 4.1 (4-10) Plt 171 (150-400) MCV 101.8 fL (80-100) Normal differential. __Urinalysis__ No proteinuria. No blood. WBC 0-2 RBC 0 Squamous Cells 0-5 No casts. ---- //What aspects of the patient's history and presentation are not consistent with typical acute decompensated HFpEF?// <<textarea "$history" "Type in your answer.">> //What studies would you order now and why?// <<textarea "$workup" "Type in your answer.">> <<button "Submit your answers." "Patient History 2">><</button>>

//Here's what you found to be uncommon regarding the patient's history and presentation:// <<print $history>> //Here's the workup you want to order:// <<print $workup>> ---- How do your answers compare to those of a master clinician? Uncommon elements of the patient's history and presentation: * This patient does not have a history of hypertension, the most common risk factor for HFpEF. * The significant volume overload (severe peripheral edema and pulmonary edema) is seemingly disproportionate to the patient's degree of heart failure, especially without concurrent nephrotic syndrome or cirrhosis * On auscultation, the patient has persistent splitting of the S2 heart sound. This can suggest a RBBB or pulmonary HTN. Other diagnoses such as pulmonic stenosis or a severe mitral regurgitation/VSD can cause persistent S2 split, however the patient lacks the findings of a diastolic and pansystolic murmur respectively. What studies to order and why: * The patient's presentation suggests worsening heart failure with probably development of significant right-sided heart failure. As such, an electrocardiogram and echocardiogram are of importance. ---- <<button "Next Section, Results and Differential Diagnosis" "Diagnosis">><</button>>

''Physical Exam'' __Vitals:__ BP 116/69, HR 90, RR 18, Temp 36.4 C (97.5 F), SpO2 100% on RA __General:__ Alert and Oriented x3. No acute distress. Appears comfortable. BMI 40. __HEENT:__ No pallour or icterus. Pupil equal. EOMI. Moist oral mucosa. No pharyngeal erythema. Hearing normal. Dilated neck veins and prominent jugular venous pulse. __Cardiovascular:__ Heart rate regular with audible S1 and S2. Persistent splitting of S2. No murmurs. Peripheral pulses palpable and symmetric. 3+ pitting edema bilaterally from the dorsum of the feet to the scrotum and lower abdominal quadrants. __Respiratory:__ Respirations non-laboured. No wheezing. Diminished breath sounds at the right lung base. Bilateral inspiratory crackles, worse on the right. __Gastrointestinal:__ Obese, soft, non-tender, non-distended. Bowel sounds present. __Neurological:__ Cranial nerves II to XII grossly intact. Motor and sensory systems symmetrical and intact. Reflexes difficulty to elicit. __Skin:__ Warm and intact. No notable erythema or obvious lesions. __Psychiatric:__ Cooperative, calm, pleasant. ---- The patient has already had some labwork completed (see below). __Chemistry__ Na 142 mmol/L (135-145) K 4.3 mmol/L (3.5-5) Cl 105 mmol/L (95-105) CO2 30 mmol/L (18-24) BUN 24 mg/dL (8-21) Cr 1.13 mg/dL (0.8-1.3) Mg 1.9 mEq/L (1.5-2) Ca 10.4 mg/dL (8.5-10) __Hematology__ Hgb 11.5 g/dL (13-17) Hct 33.4% (40-52) WBC 4.1 (4-10) Plt 171 (150-400) MCV 101.8 fL (80-100) Normal differential. __Urinalysis__ No proteinuria. No blood. WBC 0-2 RBC 0 Squamous Cells 0-5 No casts. ---- //What physical exam and/or lab findings stand out as most significant?// <<textarea "$exam" "Type in your answer.">> //Below is your existing differential diagnoses. How does the above data change your differential? Type in your top three differential diagnoses at this time.// <<print $ddx>> <<textarea "$ddx2" "Type in your answer.">> ---- <<button "Submit your Answers." "Physical Exam 2">><</button>>

//Here's your interpretation of the physical exam and lab findings:// <<print $exam>> //Here's your current differential diagnoses:// <<print $ddx2>> ---- How do your answers compare to those of a master clinician? Physical Exam and Lab Findings * Text ---- <<button "Next Section, Workup" "Workup">><</button>>

//Here's your existing differential diagnoses list:// <<print $ddx2>> ---- //Given the current history and data, what investigations would you like to order?// <<textarea "$workup" "Type in your answer.">> <<button "Submit your Answers." "Workup 2">><</button>>

Transthoracic Echocardiogram Report (from 3 months prior): * Normal LV size and shape * Normal LV wall thickness * Normal LV systolic function with LVEF 55-60% * Restricted LV filling pattern consistent with mild diastolic dysfunction. * Mildly elevated LA pressure * Normal RV size and shape * Normal RV wall thickness * No evidence of valvular stenosis or regurgitation. <<if hasVisited("Diagnosis")>><<button "See New Echocardiogram" "Diagnosis">><</button>><</if>> <<button "Previous Section" "Introduction, Patient History & Exam">><</button>>

Electrocardiogram (from 2 years prior) <<button "Previous Section" "Introduction, Patient History & Exam">><</button>> <<if hasVisited("EKG2")>><<button "See new EKG" "EKG2">><</button>><</if>> [img[https://www.gk-md.com/wp-content/uploads/2019/12/ZebraEKG1.jpg]]

//This is what you were considering ordering for your workup:// <<print $workup>> ---- How does your workup compare to that of a master clinician? ---- <<button "Next Section, Diagnosis" "Diagnosis">><</button>>

Here's what those tests revealed: __Electrocardiogram:__ * [[Click here to see EKG|EKG2]] * [[See baseline EKG (from 2 years prior)|EKG]] __Transthoracic Echocardiogram:__ * Normal LV cavity size * Mild concentric left ventricular hypertrophy * Normal LV systolic function with EF 55-60% * Restricted LV filling pattern consistent with moderate diastolic dysfunction * Dilated LA * Moderately dilated RV measuring between 3.8 to 4.1 cm * Moderately impaired RV systolic function * Dilated RA * No evidence of valvular stenosis or regurgitation * [[See baseline echocardiogram (from 3 months prior)|echo]] ---- //What are your thoughts regarding the EKG and echocardiogram findings?// <<textarea "$interpretation" "Type in your answer.">> //What is your differential diagnosis?// <<textarea "$ddx" "Type in your answer.">> <<button "Submit your Answer" "Diagnosis 2">><</button>>

Electrocardiogram <<button "Previous Section" "Diagnosis">><</button>> <<button "See baseline EKG (from 2 years prior)" "EKG">><</button>> [img[https://www.gk-md.com/wp-content/uploads/2019/12/ZebraEKG2.jpg]]

//Here's what you thought of the test results:// <<print $interpretation>> //Here's your differential diagnosis:// <<print $ddx>> ---- How does your interpretation and differential compare to that of a master clinician? * The new EKG and echocardiogram have a few unusual features and dramatic changes developing in just 3 months. * The current EKG shows new onset low QRS voltage despite evidence of concentric LVH on the new echocardiogram. * The echocardiogram has new evidence of concentric LVH, significant RV systolic dysfunction, and biatrial enlargement--all in the absence of hypertension (re: LVH) and valvular heart disease [[See New Echocardiogram|Echo2]] [[See baseline Echocardiogram|echo]] [[See new EKG|EKG2]] [[See baseline EKG (from 2 years prior)|EKG]] * Let's start putting everything together. * We have a patient showing clinical signs of decompensated heart failure. * Their workup has shown rapid development of QRS voltage & LV size mismatch, increased LV thickness without hypertension, dilated cardiac chambers, and pulmonary hypertension. * These findings should raise suspicion for rapidly developing restrictive cardiomyopathy. * However our differential must also include conditions that resemble restrictive cardiomyopathy, especially as they can be treated. //What cardiac condition can resemble restrictive cardiomyopathy and must be ruled out?// <<textarea "$ddx2" "Type in your answer">> ---- <<button "Proceed to Final Differential Diagnosis" "Summary">><</button>>

//What cardiac condition can resemble restrictive cardiomyopathy and must be ruled out?// <<print $ddx2>> ---- //Were you right?// * Our differential diagnosis in this case must include constrictive pericarditis as it is treatable. * Conversely, restrictive cardiomyopathy has a poor prognosis. As such, always put in the effort to rule out something that can be treated and/or cured. ---- //With that in mind, what are the common risk factors for constrictive pericarditis?// <<textarea "$pericarditis" "Type in your answer">> //What are the common causes of restrictive cardiomyopathy?// <<textarea "$restrictive" "Type in your answer.">> <<button "Proceed to Next Section" "Summary 2">><</button>>

__Transthoracic Echocardiogram:__ * Normal LV cavity size * Mild concentric left ventricular hypertrophy * Normal LV systolic function with EF 55-60% * Restricted LV filling pattern consistent with moderate diastolic dysfunction * Dilated LA * Moderately dilated RV measuring between 3.8 to 4.1 cm * Moderately impaired RV systolic function * Dilated RA * No evidence of valvular stenosis or regurgitation * [[See baseline echocardiogram (from 3 months prior)|echo]]

//With that in mind, what are the common risk factors for constrictive pericarditis?// <<print $pericarditis>> //What are the common causes of restrictive cardiomyopathy?// <<print $restrictive>> ---- The common risk factors for constrictive pericarditis can be explored through the history and basic lab findings. They include: * Viral pericarditis * Post-cardiac surgery * Post-radiation therapy * Connective tissue disease * TB * Malignancy * Trauma * Uremic Pericarditis * Sarcoidosis * Asbestos * Drug-induced (e.g. minoxodil, hydralazine, and other lupus causing drugs) Restrictive cardiomyopathy is typically secondary to another process or syndrome. These include: * Infiltrative heart disease (e.g. amyloidosis, sarcoidosis, hemochromatosis) * Scleroderma * Hypereosinophilia syndrome * Carcinoid Heart Disease * Radiation * Metastatic disease * Drug-induced (e.g. methysergide, busulfan, ergot, antracyclines) ---- //Which cause of restrictive cardiomyopathy is most likely in this patient?// [[See patient history, exam, and lab findings|Introduction, Patient History & Exam]] [[See New Echocardiogram|Echo2]] [[See baseline Echocardiogram|echo]] [[See new EKG|EKG2]] [[See baseline EKG (from 2 years prior)|EKG]] <<textarea "$restrictive2" "Type in your answer.">> ---- <<button "Proceed to Next Section" "Summary 3">><</button>>

//Which cause of restrictive cardiomyopathy is most likely in this patient?// <<print $restrictive2>> ---- //Were you right?// This patient most likely has cardiac amyloidosis. What details make this likely? * Cardiac Amyloidosis must be suspected when there is unexplained heart failure, especially when the echocardiogram shows increased LVH with a non-dilated LV cavity and when the EKG has low voltage (LVH - EKG voltage mismatch) ---- //What studies should be ordered next to evaluate for amyloidosis?// //What interventions are needed from cardiology?// [[Click here to review the extended workup and final diagnosis!|https://www.gk-md.com/wp-content/uploads/2019/12/Zebra-1.pdf]]