Chidinma Chima-Okereke MD
Department of Pulmonary Medicine
Cedars Sinai Medical Center
Los Angeles, CA
Chief Complaint: Difficulty breathing
History of Present Illness
A 49-year-old gentleman with history of hepatitis C cirrhosis complicated by ascites presented to the emergency room of Olive View Medical Center in San Fernando Valley, California complaining of worsening shortness of breath. The patient reports that he occasionally has shortness of breath, usually about 2-3 times a year. However for the past 2 months, he has had worsening dyspnea on exertion and cannot walk further than 5 minutes. He also reports orthopnea and paroxysmal nocturnal dyspnea. He has been having a dry cough for the past 3-4 weeks.
He has a history of chronic ascites that has required multiple taps. He has been taking his prescribed diuretics however instead of taking these medications daily he takes them about every other day due to financial constraints.
However, his abdominal distention and his lower extremity swelling are stable. He reports some nausea with decreased appetite. He also has a new symptom of left-sided chest pain that radiates down his left arm and shoulder that lasts about 20 minutes and has no associated symptoms. .
He denies any fevers or chills or weight change. He has no sick contacts.
Past Medical and Surgical History
- Hepatitis C cirrhosis
- Chronic lower extremity edema
- Ascites, status post multiple large volume paracentesis
- History of chronic abdominal pain treated with morphine
- Status post chest tube when he was a 17-year-old due to a gunshot wound
- History of incarceration, released about 8 months ago
- 6-pack of beer a day – quit 12 years ago.
- Former smoker, quit 10 years ago, 7 pack-years
- IV heroin use 15 years ago
- No cocaine, amphetamines or any inhaled substances
- No recent travel, occupational, pet or bird exposures
- Lives with his fiancé in Lancaster, California
- Father died of an MI at age 56.
- Mother - SLE, DM, Stroke
- Sister - Colon cancer
- Brother - Hepatitis C cirrhosis
- Controlled-release morphine sulfate 15 mg p.o. every morning and 30 mg p.o. every evening.
- Furosemide 40 mg p.o. daily.
- Spironolactone 50 mg p.o. daily.
- Lactulose 15 mL p.o. b.i.d. p.r.n.
Review of Systems
Positive for pleuritic chest pain, night sweats, chills, dry cough - unproductive of sputum, lightening and darkening of urine, lower extremity edema, palpitations, decreased appetite, dry mouth, joint stiffness in the morning.
- Vital signs: T 97.4 BP 115/67, HR 89, RR 20, SpO2 93%/RA
- Lung exam was significant for bilateral crackles midway up the back.
- Abdominal exam was non-tender and not suggestive of ascites
- Lower extremities: 1+ bilateral pitting edema up to the knees.
- Multiple skin tattoos and erythema in his lower extremities
- Muscle strength was 3/5 in the lower extremities, 4/5 in upper extremities bilaterally.
- Otherwise the physical exam was unremarkable.
- Basic Metabolic Panel was within normal limits.
- Complete blood count (CBC): White count 6.3 X 103/mm3 with 8.3% eosinophils, hemoglobin 12.3 g/dL, platelets 130,000/µL.
- Liver function tests (LFTs): AST 78 IU/L, ALT 42 IU/L, alkaline phosphatase 115, total bilirubin 1.3 mg/dL, INR 1.3, albumin 2.7 g/dL.
- Brain naturetic peptide (BNP) 38 ng/L, troponin is 0.008 ng/ml.
A chest x-ray was obtained (Figure 1).
Figure 1. Admission AP (Panel A) and lateral (Panel B) chest x-ray.
The chest x-ray was interpreted as poor inspiration with elevation of the right diaphragm. The heart is at least upper limits of normal in size. Pulmonary vessels are congested. The azygos vein is mildly dilated. No significant pleural effusion is detected in these two views.
A CT angiogram was obtained to rule out pulmonary embolism (Figure 2).
Figure 2. Panels A-D: Representative static axial images from the thoracic CT scan lung windows. Lower panel: movie of representative axial thoracic CT scan lung windows.
He was admitted to the medicine wards, diuresed with furosemide 40 mg IV, spironolactone 100 mg by mouth and fluid restricted.
At this point which of the following are diagnostic tests that should be ordered? (click on correct answer to move to next panel)
- Coccidiomycosis serology
- Quantiferon TB and sputum AFB
- Rheumatologic work up including anti-neutrophil cytoplasmic antibody (ANCA), ANA and subtypes, RA and anticentromere antibodies
- All of the above