Case 25 Cardiology

Dyspnea

Work it one clue at a time. The diagnosis stays hidden until you reveal it.

Clue 1

A 70-year-old man presents with dyspnea. What do you notice when you first meet him?

Clue 2

This finding should generate a hypothesis, which we will circle back to eventually. Before we do, let’s talk about dyspnea. The two main systems responsible for dyspnea are the heart and the lungs.

Clue 3

The jugular venous pulse can serve as a pivot point. It can take you toward or away from the heart. With this in mind, let’s evaluate the patient’s neck. Here, he is in the upright position. (Sometimes the jugular venous pulse is better seen on the left.)

Clue 4

The JVP is elevated. We know we are dealing with something related to the heart.

Clue 5

More history reveals orthopnea and PND. Our patient has the clinical syndrome of heart failure. Systolic function is preserved on echo.

Clue 6

Let’s return now to our initial physical finding. Is there a cause of diastolic HF on that framework that is associated with easy bruising and “raccoon eyes”?

Clue 7

Our hypothesis leads us to order an EKG. What are we specifically looking for on the EKG?

“The eyes can’t see what the mind doesn’t know.”

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