case-4
نویسنده خبر : مدیر سایت    
تاریخ درج خبر : 1397/5/9

A 64-year-old woman presents to the emergency department with

A 64-year-old woman presents to the emergency department with shortness of breath while at rest, nonproductive cough, and lower extremity swelling for the past 2 days. She reports that she was able to walk less than one block and climb less than one flight of stairs because of shortness of breath. She explains that she has to use two pillows at home to sleep. She denies any fever, chills, or chest pain. Her urine output was usual. She further explains that since the day before her symptoms started she was feeling "overwhelmed" because of news about her husband being diagnosed with metastatic colon cancer.

Her past medical history is significant for the following:

Type 2 diabetes mellitus

Hypertension

Hyperlipidemia

Obesity

Chronic kidney disease (stage 2)

Obstructive sleep apnea

Her family history is positive for hypertension and diabetes on both her mother's and father's side. She denies smoking cigarettes, illicit drug use, and significant alcohol use.

A physical exam reveals blood pressure of 183/84 mm Hg, heart rate of 77 beats/min, respiratory rate of 20 breaths/min, oxygen saturation of 90% on room air, temperature of 98.4°F (36.9°C), and a body mass index of 35.5 kg/m2. She is awake and alert.

Jugular venous distention is noted. Upon auscultation, bilateral crackles are present in the lower two thirds of the thorax. Her heart sounds are audible and regular, with normal S1 and S2. An S3 gallop is present. No audible murmurs are noted. Apex impulse is present and nondisplaced from the midclavicular line. Her abdomen is soft, nondistended, and nontender to palpation. Moderate bilateral pitting edema in the lower extremities is present.

Initial laboratory workup reveals a serum creatinine level of 1.2 mg/dL (same as baseline level). Her brain natriuretic peptide (BNP) level is 4,237 pg/mL. Her serum troponin I level is 0.42 ng/mL. Lipase and liver function test results are within normal limits. Her ferritin level is 150 ng/mL. Her plasma and 24-hour urine fractionated metanephrine and catecholamine levels are within normal limits. Urine drug screen results are negative for cocaine.

An ECG reveals sinus rhythm with a heart rate of 75 beats/min and new T-wave inversion in the anterolateral leads compared with a previous ECG. Chest radiography reveals diffuse patchy opacities on bilateral lung fields that are suggestive of moderate pulmonary edema and blunting of costophrenic angle, which is suggestive of bilateral pleural effusion. Two-dimensional (2D) transthoracic echocardiography reveals hypokinesis of the septal, lateral, and anterior mid-distal segments with a left ventricular ejection fraction of 30% to 35% .

Given the patient's symptoms, ECG changes, elevated troponin levels, and 2D echocardiography findings, urgent left heart catheterization with angiography is performed. Coronary angiography reveals 40% obstruction of the left anterior descending artery, 30% obstruction of the left circumflex artery, and 30% to 40% obstruction of the right coronary arteries. Left ventriculography revealing systole .

Which of the following is the most likely diagnosis?

A- Acute-on-chronic heart failure secondary to hypertensive emergency

B- Acute-on-chronic heart failure secondary to myocardial ischemia

C- Acute-on-chronic heart failure secondary to Takotsubo cardiomyopathy

D- Pulmonary hypertension World Health Organization classification group I

 

 

 

 

 

Answer ( C )

 

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