A 54-Year-Old Woman With Shortness of Breath: Part 2
In part 1 of this 2-part series, we reviewed a case involving a 54-year-old woman who presented with a new report of shortness of breath that was occurring for several days.
The patient is an otherwise healthy woman whose only other medical diagnosis is minimal hypertension, which is well-controlled with the use of an angiotensin-converting-enzyme inhibitor. The shortness of breath presented subacutely and was not accompanied by fever, cough, purulent sputum, hemoptysis, nor significant chest pain.
During detailed questioning, the patient noted intermittent minor pain with deep inspirations. The patient is a certified public accountant, mainly doing desk work, but she maintains an active lifestyle. She is recently menopausal and has not used hormonal medications for at least 10 years. Additionally, she has not smoked cigarettes since attending college. She has had two uncomplicated pregnancies, and her children are now 30 and 27 years old, respectively.
As noted in part one, the data collected from her physical exam (Table 1) and diagnostic testing (Table 2) suggested a high likelihood of pulmonary embolism (PE). Later, a pulmonary CT angiogram study was performed and confirmed PE. A cardiac EKG reveals normal ejection fracture, except for the presence of flattening of the interventricular septum.
Table 1. Physical exam
BP
110/70
respirations
18/min
pulse
100/min
O2 saturation room
93%
Temperature
37˚C.
Table 2. Diagnostic testing
Tachycardia with no significant cardiac murmurs or gallops
Lungs: Clear
Lower extremities: Symmetrical with no calf pain or edema
EKG shows sinus tachycardia
Routine CBC and metabolics are within normal limits
Cardiac troponins: 0.8 ng/L (nL < 0-0.4 ng/L)
D-dimer assay level: 1100 ng/mL (nL < 500 ng/mL)
COVID-19 test: Negative
EKG shows flattening of the interventricular septum
(Answer and discussion on the next page).