A 24 year old woman with shortness of breath.pptVIP

A 24 year old woman with shortness of breath History of Present Illness A 24 y/o woman presented to the outpatient clinic after developing episodic shortness of breath, particularly on exertion. The symptoms were associated with chest pain and a dry cough. This problem has become progressively worse over the past 5 months, and she recently had an episode of syncope that occurred while running up a flight of stairs. History of Present Illness(Continued) She denied any history of wheezing, rhinitis, paroxysmal nocturnal dyspnea, fever, weight loss, night sweats, rash, or joint pain. She has no significant past medical history, and takes no medications. The patient is also a non-smoker, and is currently a college student. What is a preliminary differential diagnosis? Asthma Arrhythmias Congenital heart disease Pulmonary hypertension Sarcoidosis Panic attacks Myocardial ischemia Physical Exam Vitals: Afebrile, HR 120 bpm, BP 100/60, RR 16, O2 saturation 95% on room air. HEENT: Elevated JVP Lung Exam: Normal Cardiac Exam: Regular tachycardia, II/VI holosystolic non-radiating murmur at the lower left sternal border, accentuation of the pulmonary component of the 2nd heart sound (P2) Extremities: No peripheral edema What is the grading system of systolic murmurs? Grade 1 – Soft Grade 2 – Moderate Grade 3 – Loud Grade 4 – Associated with a thrill Grade 5 – Audible with the stethoscope only partly resting on patient’s chest Grade 6 – No stethoscope needed What are the causes of a loud P2? Pulmonary Hypertension Congenital heart disease resulting in left to right shunts Routine Lab Tests CBC, chem 7 were unremarkable. What diagnostic tests should be ordered next? Chest X-ray EKG Exercise oximetry Chest X-ray EKG What are some causes of a tall R wave in lead V1? Right ventricular hypertrophy Right bundle branch block Wolff-Parkinson-White syndrome Posterior MI Normal variant (seen in children and teens, but rare in adults) Exercise O2 Saturation Although the patient h