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  • 48 year old male  without significant PMH who presents with subacute dyspnea on exertion.
  • sporadic episodes of palpitations with light-headedness.
  • past few weeks
    • new progressive dsypnea on exertion
      • most prominent when he climbs the stairs
      • new orthopnea,
      • episodes of PND
      • intermittent dizziness
      • RUQ pain, and nausea and vomiting
      • denies
        • LE edema,
        • CP,
        • syncope.
  • mildly tachycardic (100s)
  • hypertensive (140s/100s),
  • satting well on RA.
  • Exam
    • epigastric tenderness.
  • Labs notable
    • unremarkable CBC, CMP, d-dimer 1000, troponin 0.033 to 0.040, BNP 515.
    • CXR showed cardiomegaly and increased interstitial markings, small bilateral pleural effusions,
    • h/o hepatic hemangioma and tobacco use (3 cig/day) who presented with new HFrEF diagnosis and volume overload associated with elevated troponin and intermittent runs of Vtach.
    • CHF service consulted for new acute heart failure of unclear etiology. Pt is s/p left and right heart cath which showed no CAD and low cardiac filling pressures consistent with euvolemia/mild hypovolemia 2/2 diuresis. Pt now on oral medications and started on GDMTProblem Course:
      V-tach
      intermittent 8-12 beat runs of Vtach since admission. Concern for underlying ischemia and/or ? Sarcoidosis as etiology for CM
      TSH was normal

      Tobacco use
      patient reports smoking 3 cigarettes per day since age 16 – denies smoking more than 3 per day over this time

      * Acute HFrEF (heart failure with reduced ejection fraction)
      acute exacerbation with volume overload. New diagnosis. Etiology is broad but most likely 2/2 ischemic CM vs hereditary vs other infiltrative process (HH, sjogren’s, other autoimmune processes).
      Although ischemic is most likely pt had Cardiac Cath on  which showed no CAD therefore not 2/2 ischemia.

      Other diagnoses include hereditary, idiopathic, or infiltrative

      TTE showed EF 15-20% with indeterminate diastolic dysfunction
      BNP was 515 on admission
      CXR showed interstitial markings and small bilateral pleural effusions
      TSH was normal. Patient denies etoh / substance use
      Unknown dry weight

 

 

 

Perihilar interstital opacities are consistent with pulmonary edema.
Mild emphysematous changes at bilateral apices
Bilateral pleural effusions R>L
11mm R Hilar Node
Cardiomegaly.