70 yo F with a history of chest pain and shortness of breath

Original case by Brandon Fainstad, MD.
Edits and graphics by Yilin Zhang, MD.


OBJECTIVES:


CASE:

70 year old woman was in her usual, high functioning state of health until 8 weeks prior to presentation when she developed an episodic headache that started over the top of her head and radiated to her temples and jaw. Her headache was worse with eating but had no associated vision changes and spontaneously resolved 2 weeks ago. About 4 weeks ago she developed a dry cough and for the past two weeks she has experienced chest pressure and SOB when climbing a flight of stairs. Initially, the chest pain and SOB would resolve after a brief rest but today they developed while walking on flat ground and did not resolve until after resting for 10 min.  She also admits to new 2 pillow orthopnea, increased swelling in her legs and 5lb weight gain over the past 10 days.  She denies any ongoing headache or fevers, chills, nasal congestion, sore throat or rashes.  She has no known medical problems and does not take any medications.  She has never smoked and rarely drinks a glass of wine.  

On exam she is afebrile, HR 87, BP 170/90 in both arms, RR of 22 and SpO2 of 97% on room air.  She appears comfortable at rest, no tenderness over her jaw or temples, no increased work of breathing, but does have dullness to percussion at L lung base with bilateral basilar crackles. Heart rhythm is regular with a 3/6 systolic murmur loudest at the apex and a friction rub audible over the anterior precordium, JVP to 8 cm H2O and and trace dependent edema. No rashes appreciated.

Labs
  • Na 132, BUN 25, Cr 1.2, Glu 125
  • WBC 12, Hct 26, Plt 400
  • Alb 3.0 otherwise LFTs nml
  • Trop 0.05
  • BNP 250
  • ESR 115, CRP 150

EKG

ECG


CXR

CXR


What is your differential for his cardiac silhouette and what would be your next step in evaluation? 


What could you do to further assess the patient before calling cardiology? 


How can you tie together this patient’s presentation and clinical findings?


How can you differentiate between aortitis (inflammatory) versus non-inflammatory aortic aneurysm?  


OUTCOME:


TEACHING POINT (adds ~ 5-7 min)  


TAKE HOME POINTS:


REFERENCES:

  1. Roy CL, Minor MA, Brookhart MA, Choudhry NK. Does This Patient With a Pericardial Effusion Have Cardiac Tamponade?. JAMA. 2007;297(16):1810–1818.
  2. Hoffman GS. Giant Cell Arteritis. Ann Intern Med. 2016;165:ITC65–ITC80.
  3. Buttgereit F, Dejaco C, Matteson EL, Dasgupta B. Polymyalgia Rheumatica and Giant Cell Arteritis: A Systematic Review. JAMA. 2016;315(22):2442–2458