A 41-year-old woman with a history of obesity and osteoarthritis complains of years of fatigue and shortness of breath on exertion, which is seemingly worsening over the past month.  She also complains that she feels her voice has become more hoarse during this time.  She has no history of chest pain, diaphoresis, nausea, back pain, or orthopnea.  She has financial and social stressors, and has not seen a physician for her complaints.

In the ED, T 98.9 HR 88 RR 22 BP 130/90 98% RA.  On examination, she is sitting up, appears tired, and is in no apparent distress.  As you auscultate her heart, she asks whether you hear her murmur – “I’ve had a murmur my whole life” – you do not appreciate a murmur on examination.  The rest of her cardiovascular exam is significant for 1+ pitting edema above her ankles, with normal arterial pulses throughout.  She has a positive hepato-jugular reflux exam.  Her lung exam is normal.  ECG and chest radiograph are non-specific.

Which is the next BEST step in this patient’s management:

    A.    Draw thyroid function tests, and if normal, follow up with primary care
    B.    Start her on a daily diuretic medication such as hydrochlorothiazide and follow
            up with primary care
    C.    Counsel her on weight management and screen for depression
    D.    Obtain a screening echocardiogram

In the meantime, a quote –

“Medicine is an art, and attends to the nature and constitution of the patient, and has principles of action and reason in each case.”

– Plato (429-327 B.C.)


“All things are hidden, obscure and debatable if the cause of the phenomena be unknown, but everything is clear if this cause be known.”

– Louis Pasteur (1822-1885)


02/25/2013 8:58pm

My vote is for the echo (D). She may have OSA with her obesity, setting her up for pulmonary HTN. She likely had a VSD and L to R shunt, but if her HTN is worsening, her RV pressures are more elevated decreasing the shunt (or reversing it slightly) causing her decreased murmur.

Sean Fox
02/25/2013 8:59pm

Well thought out.

02/25/2013 9:01pm

D - perhaps a worsening regurg murmur that now is too wide open to cause any audible turbulence

02/25/2013 10:04pm

Some great replies here!


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