Lexa Bennett: The Case

HPI:

Mrs. Lexa Bennett 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 minimal improvement. The following month her shortness of breath returned, especially at night, such that she would use 2-3 pillows to keep from coughing. At this time, 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 prescription for 2-weeks of prednisone, 60 mg daily, which made her feel less fatigued 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: eczema that resolved in her early 20s and anemia. She has been pregnant 3 times, miscarried once at 15 weeks gestation then delivered 2 healthy term children, the last of which was born 4 months ago.

 

Allergies:  Penicillin, Latex

 

Medications:  MVI, Iron supplement

 

Family history: her mother has type 1 diabetes and heart disease (had a heart attack at age 45) and her father died of colon cancer at age 60. Her sister and brother have both had “blood clots in the legs.”

 

Social history: lives with husband and 2 children in Louisville, nonsmoker and nondrinker, admits to having used methamphetamines in the past, but none since she found out she was pregnant with the youngest child, she denies using any other illicit substances

 

Review of systems:

+intentional 40 lb weight loss after the delivery of her child, but she has regained 20 lbs in the last month

+fatigue, decreased appetite, intermittent abdominal pain

+history of MRSA skin infection after C-section with last baby

 

Physical Exam:

T	37.2º
BP	102/88
RR	20
HR	107
SpO2	91%
BMI	30

 

Korotkoff sounds are heard at 130 mmHg with inspiration and 134 mmHg with expiration.  The intensity of her pulse alternates with every beat.

 

Gen: coughing persistently, worse with position changes.

HEENT: NC/AT, sclera anicteric, MMM, trachea midline, no cervical lymphadenopathy

CV: Jugular vein pulse seen 10 cm above sternal angle with head of bed at 30 degrees. Heart sounds are regular with no murmurs or rubs, but an S3 gallop is present

Lungs: breath sounds equal bilaterally, bibasilar crackles appreciated, no wheezes or rhonchi, no dullness to percussion, no egophony

Abdomen: mildly distended, dull on percussion

Extremities: Pitting edema to the knees bilaterally

 

Diagnostic testing data: 

-CBC: WBC 12,600, hemoglobin 10g/dL, platelet count 509,000

-BMP: Na 133, K 3.3, Cl 107, HCO3 20, BUN 10, Cr 0.82, Glucose 99

-PT/PTT/INR are normal

-Hepatic function panel: Albumin 3.1, serum protein 6.4, alkaline phosphatase 64, bilirubin 0.6, alanine aminotransferase 159, aspartate transferase 164

-Troponin 0.01

-ProBNP 7780pg/mL

-A D-dimer was minimally elevated at 0.6 micrograms/mL (nl <0.5)

-Arterial blood gas measurement shows pH 7.45/PaCO2 30/PaO2 60. Supplemental oxygen is provided for comfort.

 

EKG is shown below.

 

 

A chest x-ray is shown below.

 

While a chest CT with contrast is negative for pulmonary embolism, it does show cardiomegaly with no significant pericardial effusion.

 

The ER physician calls the cardiology team to admit the patient to the hospital for further assessment and treatment.

 

The cardiology team repeats the history and physical exam and reviews the test findings so far. Due to the abnormalities on initial workup, an echocardiogram is performed and a right heart catheterization is planned.

 

Transthoracic Echocardiogram showed the left ventricle is moderate to markedly dilated with normal wall thickness and severely reduced systolic function, EF 10-15%. Moderate to severe mitral regurgitation, no other major valvular abnormalities. The right ventricle is of normal size and grossly normal function.

 

Right heart cath shows:

Right atrial pressure	18 mmHg
Pulmonary arterial pressure	54/28 mmHg
Pulmonary capillary wedge pressure	25 mmHg
Mixed venous oxygen saturation	32%
Cardiac output	2.93 L/min
Pulmonary vascular resistance	496

After Mrs. Bennett reports she is not breastfeeding, furosemide and lisinopril are started as well as prophylactic dose low-molecular-weight heparin. She is introduced to a registered dietician to discuss dietary recommendations and the social worker visits to go over common concerns about starting a new complex medication regimen.

 

By hospital day 5, Mrs. Bennett’s dyspnea is resolved and SpO2 stays above 94% on room air. The team has added carvedilol and spironolactone to her treatment regimen. She reports feeling confident she can manage her medications, recognize symptoms of clinical worsening and make lifestyle changes that help prevent complications. She is discharged home with a scale and instructed to follow-up with the cardiologist in 1 week.