Shortness of Breath: Bedside Diagnostic ChallengeA 56-year-old woman presents with the complaint of shortness of breath.
A 56-year-old woman presents with the complaint of shortness of breath. She indicates that the shortness of breath is precipitated by exertion and is worse at end of the day, particularly during the night when she has to sit on the side of the bed to catch her breath. She also notes a recent pattern of awakening once or twice a night to urinate. She has not experienced leg swelling.
The patient emigrated from Panama 25 years ago. She remembers being “laid up with arthritis” for a number of weeks at the age of thirteen.
She is married with three grown children. She does not drink or smoke and is not receiving any medications.
Physical examination reveals an obese patient of stated age who does not appear ill.
Vital signs are:
- temperature of 98.2˚ Fahrenheit,
- blood pressure 124/70 mm Hg,
- pulse of 76 and regular, and
- respiration’s 16/minute.
Her weight is 240 lbs.
There is moderate jugular venous distension.
Examination of the lungs reveals moist inspiratory rales at both bases. Heart sounds are distant.
A grade 3 systolic murmur is noted at the left sternal border. It is not possible to tell whether the murmur radiated. The 2nd heart sound is normal. The jugular venous pulse is elevated and the carotid pulse is delayed.
There are no other abnormal findings on the physical examination.
What is most helpful in distinguishing aortic stenosis from mitral insufficiency?
Characteristics of the heart murmur
Elevated jugular venous pulse
Delayed carotid pulse
No history of syncope or angina
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About The Bedside Diagnostics Blog Series:
Except for Hospitalists, Emergency Medicine physicians, and Interventional Cardiologists, most physicians will spend the bulk of their professional time with patients in an office setting.
Here is where finely tuned clinical skills are most important in leading to accurate diagnoses, fewer complications resulting from unnecessary tests and procedures, and lower costs. These Bedside Diagnostic Challenges reinforces the value of these clinical skills and tests users on their knowledge of them.
Bedside Diagnostic Challenge questions are issued periodically every month as a free benefit of Med-Challenger.
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About the Author:
Paul Griner MD, MACP graduated from the University of Rochester School of Medicine and completed his residency at the Massachusetts General Hospital, Boston, MA. He has served the University of Rochester School of Medicine as Chief Resident in Medicine and as Professor, Department of Medicine. He has served as a Senior Lecturer at Harvard Medical School and consultant at the Massachusetts General Hospital where he introduced a mentoring program for the faculty of General Internal Medicine. Dr. Griner is board certified in internal medicine.