Joanne Dixon: The Case

HPI:

Ms. Joanne Dixon is a 27-year-old woman who came to the emergency room for shortness of breath.

She first had the feeling of shortness of breath accompanied by coughing and fever 3 months ago. She went to an immediate care center and was diagnosed with pneumonia and given antibiotics, with some improvement. The following month her shortness of breath worsened and became worse when she laid down to sleep, and she saw her primary care doctor, who prescribed a betamethasone inhaler and albuterol inhaler, with little change in her symptoms. She went back to her doctor a month ago and was given a 2-week prescription of prednisone, 60 mg daily, which made her feel less short of breath at night but did not change her shortness of breath with activity. She came to the ER tonight because she called her doctor to tell her that her legs and abdomen have been swelling up for the last few days, and the doctor told her to go straight to the ER.

Past medical history:

+ Raynaud’s phenomenon for 3 years and she was treated for anemia with her last pregnancy. She has been pregnant 3 times and miscarried once at 3.5 months gestation. Her sister and brother have both had “blood clots in the legs.”

Family history:

Her mother has type 1 diabetes and heart disease (had a heart attack and cath) and her father died of colon cancer at age 60.

Social history:

Lives with husband and 2 children in Louisville, nonsmoker and nondrinker, never used illicit drugs

Review of systems:

• +45 lb weight loss over last year using home exercise videos and diet
• +dry mouth, intermittent abdominal pain, diarrhea, can’t quantify how much or how often
• +thinning hair
• +pain in all upper extremity joints for the last few years, worst in the morning
• +history of MRSA skin infection after C-section with last baby

Physical Exam:

• T 99.1, BP 200/110, RR 20, HR 100, SpO2 91%, BMI 31
• Korotkoff sounds are heard at 130 mmHg with inspiration and 134 mmHg with expiration.
• Gen: coughing persistently, worse with movement.
• Heent: + lymph nodes palpable in cervical and supraclavicular regions
• CV: Jugular Pulse seen 10 cm above sternal angle with head of bed at 30 degrees, no murmurs, rubs, or gallops
• Lungs: no wheezes, crackles, or rhonchi, no absence of breath sounds, no dullness to percussion, no egophony
• Abdomen: distended, + shifting dullness to percussion
• Extremities: Pitting edema to above knees bilaterally, swelling and redness of the right 2nd proximal interphalangeal joint

Diagnostic testing data:

• CBC, including hemoglobin, white blood cell count, and platelet count, is normal.
• Erythrocyte sedimentation rate is elevated at 40 mm/hr. (nl <20)
• PT/PTT/INR are normal
• Alkaline phosphatase, bilirubin, alanine aminotransferase and aspartate transferase are elevated. Albumin and serum protein are normal.
• serum electrolytes are normal, with the exception of serum bicarbonate of 20
• Troponin testing of serum is normal
• A D-dimer was elevated at 2.1 micrograms/mL (nl <0.5)
• Arterial blood gas measurement shows pH 7.45/PaCO2 30/PaO2 55
• EKG is shown below.

The hospitalist repeats the history and physical exam and reviews the test findings so far. Due to the abnormalities on initial workup, the hospital physician consults cardiology to perform a right heart catheterization and orders additional diagnostic tests. He also orders continuous oxygen supplementation and prophylactic dose low-molecular-weight heparin daily, and starts a calcium-channel blocking medication and thiazide diuretic. Over the next hospital day, her blood pressure improves, running 140’s/90’s. 

• A 2-D echocardiogram is performed at admission and shows right ventricular hypertrophy, left ventricular hypertrophy, and paradoxical septal motion during systole.
• Pro-B-natriuretic peptide is elevated at 1530 pg/ml (<450 nl)
• Antinuclear antibodies are positive at 1:5120 dilution (negative is 1:40 or 1:60), speckled pattern seen
• Anti-double-stranded DNA antibodies: positive at 1: 100 dilution (negative <1:10)
• Serum complement measurement shows decreased C3 and C4
• Random serum renin and aldosterone levels are elevated, with a aldosterone:renin ratio of 19
• Urinalysis shows red blood cells and protein

Right heart cath shows:

• Right atrial pressure = 18 mmHg
• Pulmonary arterial pressure = 74/33 mmHg
• Pulmonary capillary wedge pressure = 5 mmHg
• Mixed venous oxygen saturation = 32%
• Cardiac output = 2.93 L/min
• Pulmonary vascular resistance = 1283