Larger Than Life
A Unique Cause of Dyspnea in an Elderly Woman
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Information about a real patient is presented in stages (boldface type) to expert clinicians (Dr Beckman), who respond to the information, sharing their reasoning with the reader (regular type). A discussion by the authors follows.
Patient presentation: An 89-year-old woman presents to cardiology clinic with the concern of recurrent shortness of breath and dyspnea on exertion during the previous 6 months. Her symptoms are progressive such that she can no longer walk > 10 feet before becoming symptomatic. Previously, she was independent at home and able to climb stairs with groceries or laundry without difficulty. The patient reports dependent lower extremity edema, orthopnea, and paroxysmal nocturnal dyspnea, but neither chest pain, palpitations, diaphoresis, nor lightheadedness. Her medical history is significant for diabetes mellitus, hypertension, hyperlipidemia, and glaucoma. Her medications include insulin, lisinopril, losartan, furosemide, and pravastatin. She has no known medication allergies.
The patient’s most recent medical history is notable for a new diagnosis of aortic stenosis now repaired by transcatheter valve replacement (TAVR). She underwent successful valve replacement; however, her hospital and immediate outpatient course were complicated by profound hyperglycemia requiring escalating doses of insulin and readmission to a local hospital. Furthermore, the patient’s dyspnea did not change appreciably after valve replacement, and she was hospitalized twice more with acute on chronic heart failure requiring intravenous diuresis. Before discharge, she was started on high doses of oral furosemide. Ongoing symptoms of heart failure despite TAVR prompted her primary care physician to refer her to a cardiologist at a tertiary care center.
The patient’s initial examination showed an elderly appearing woman, sitting comfortably in a wheelchair with her son at her side. Her vitals in the office revealed a heart rate of 91 and blood pressure of 135/77. The patient’s head and neck examination showed a jugular venous pressure …