Digital clubbing is uncommon in patients with CHF. However, historical and examination findings supportive of a diagnosis of CHF, including orthopnea, paroxysmal nocturnal dyspnea, jugular venous distention, extra heart sounds, and peripheral edema, were all notably absent. The cardiac silhouette and pulmonary vasculature were unremarkable.Ĭhronic heart failure can present with worsening dyspnea and hypoxemia, and restrictive changes on PFTs are consistent with CHF. Chest radiography showed bilateral mixed alveolar-interstitial infiltrates with basilar predominance. Diffusing capacity of lung for carbon monoxide (Dlco) was severely reduced at 27% of predicted value. The patient was unable to complete maneuvers to determine total lung capacity. Pulmonary function tests (PFTs) revealed decreased vital capacity, forced vital capacity (FVC), and forced expiratory volume in the first second of expiration (FEV 1) with a normal FEV 1/FVC ratio, suggesting a restrictive process. The alveolar-arterial gradient was considerably elevated at 64 torr. Arterial blood gas revealed a normal pH and Paco 2 but significant hypoxemia with a Pa0 2 of 42 mm Hg while breathing room air. Electrocardiography showed normal sinus rhythm. Complete blood cell count revealed a hemoglobin of 15.4 g/dL (reference ranges provided parenthetically) (12.0-15.5 g/dL) and a white blood cell count of 8.7 x 10 9 (3.5-10.5 x 10 9), with 4.9% eosinophils (0.8%-7.2%). On examination of extremities, digital clubbing but no cyanosis or peripheral edema was noted. Lung auscultation revealed dry bibasilar inspiratory crackles, as well as fine expiratory squeaks. Cardiac auscultation revealed a regular rate and rhythm without murmurs or rubs and no elevation of jugular venous pressures. Her respiratory rate was 24 breaths/min, with an oxygen saturation of 82% by pulse oximetry while breathing room air. Her blood pressure was 110/60 mm Hg and her heart rate was 76 beats/min, both within normal physiologic ranges. Physical examination revealed a thin woman who appeared moderately dyspneic at rest. The patient had worked as a landscape designer. There was no family history of lung disease. Medications on presentation included diltiazem, clopidogrel, losartan, levothyroxine, furosemide, sertraline, and omeprazole. Her history included hypertension, gastroesophageal reflux disease, hyperlipidemia, and hypothyroidism. She had a remote smoking history of 3 pack-years approximately 50 years previously. She had no history of chest pain, orthopnea, or paroxysmal nocturnal dyspnea. This diagnosis was not supported by objective testing nor had bronchodilators been beneficial.ĭuring the preceding year, she had unintentionally lost 13.6 kg. A provisional diagnosis of asthma had been suggested before her presentation. She also reported a harsh cough with occasional clear sputum production. Walking 3 to 6 meters resulted in such severe dyspnea that she had to discontinue activity. By presentation, however, she reported severe dyspnea with only minimal exertion. Initially, her symptoms were mild and noticeable only with moderate exertion. A 73-year-old woman presented to our institution for evaluation of progressive shortness of breath that had gradually worsened during the previous year.
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