Case history
Case history #1
A 76-year-old woman presents to the outpatient clinic with increasing breathlessness on moderate exertion that has been gradually worsening in the past 6 months. She is a fairly active and healthy person except for a history of hypertension that her primary care physician has been treating for about 20 years with lisinopril and hydrochlorothiazide. She has not experienced any chest pain with exertion. On physical examination, her BP is 164/83 mmHg and she has raised jugular venous pressure with hepatojugular reflux, and no lower extremity edema. Her cardiac examination reveals a nondisplaced apical impulse, normal S1 and S2, and a fairly loud S4 with no murmurs. Investigations confirm preserved systolic function with evidence of left ventricular hypertrophy and left atrial dilatation. Her N-terminal prohormone B-natriuretic peptide is 1623 picograms/mL.
Case history #2
A 56-year-old woman presents to the emergency department with shortness of breath at rest, orthopnea, and paroxysmal nocturnal dyspnea that developed in the last 5 days. Her past medical history includes obesity, hypertension, diabetes mellitus, and chronic kidney disease stage II. She had a cardiac catheterization done 2 years ago due to exertional chest pain that revealed nonobstructive coronary artery disease. On exam she is tachycardic with a heart rate of 110 bpm and her blood pressure is 192/98 mmHg. She has jugular venous distention up to her jaws, trace lower extremity edema, and bibasal crackles. She has a normal S1 and S2, but has a summation gallop with no murmurs.
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