A 44-Year-Old Woman With Worsening Fatigue and Shortness of Breath With Exertion

Introduction. A 44-year-old woman presents for evaluation with new fatigue and worsening shortness of breath with exertion.

Patient history. The patient noted that she has valvular heart disease related to an episode of rheumatic fever at 12 years of age, which occurred in her native Puerto Rico. Since then, did not have any symptoms until a year ago when she reported the onset of mild exertional dyspnea, which has gradually increased to the point where she has shortness of breath when walking one to two blocks or when climbing one flight of stairs. There is no associated chest pain, exertional or otherwise. More recently, within the last month, she has developed significant fatigue and tiring even in the absence of dyspnea.

The patient has been diagnosed with diabetes mellitus, which she treats with metformin 1000 mg two times a day. She reports that her HbA1C has been "good," usually less than 7. She has two grown children and reports no problems with her pregnancies. She does not smoke.

Physical examination. Her physical examination reveals a 44-year-old woman with vital signs showing a normal temperature of 98°F, respirations of 14/min, and a pulse rate of 64 beats per minute. Her head, eyes, ears, nose, and throat examination shows normal non-inflamed pharynx and tonsils.

There is pallor of her conjunctivae, and her chest is clear to auscultation. Her cardiac examination reveals regular rhythm with the presence of a somewhat harsh holosystolic murmur best heard near the cardiac apex. There is 1+ ankle edema bilaterally.

Her laboratory tests show: Hb 9.5 gm/dL with mean corpuscular volume, white blood cell count, and platelets, all within normal ranges. Her glucose level is 125 mg/dL and her A1C is 6.7. A reflex blood smear report reveals a reticulocytosis of 5.3% and the presence of 3 to 5 fragmented red blood cells (RBC) per high-power field. Metabolic panel included a lactate dehydrogenase (LDH) of 525 U/L and bilirubin slightly elevated to 2.2 mg/dL. The patient’s electrocardiogram showed her sinus rhythm within normal range, left atrial abnormality, but no ischemic changes or acute injury currents.