Case Answers:

Case answers will be presented after review of the HPI.

Answer 1
The students should be reminded that there should always be an organized approach to the initial assessment of the patient with dyspnea. The wide variety of conditions that can cause dyspnea can be divided, for ease of initial assessment, into cardiac and pulmonary disorders. As is the case frequently in ambulatory medicine, this patient has both. The challenge is to sort out the clinical data and to determine which is the principal cause of his dyspnea.

The data that points to cardiac etiology:

• Age, sex, obesity, hypertension, smoking history.
• History of CAD.
• The orthopnea and decreased exercise tolerance don’t discriminate, but the possible PND does.
• The physical findings of JVD and the accentuated P2 also do not help differentiate since they reflect pulmonary hypertension.
• The presence of a systolic gallop, basilar rales and the murmur (mitral regurgitation?), as well as the edema, do help, pointing to left ventricular dysfunction.

The data that points to respiratory etiology:

• The chronic smoking history.
• The history suggestive of chronic bronchitis.
• The findings of increased AP diameter, hyperresonance, diminished breath sounds and the prolonged expiratory phase, all indicate COPD.

Answer 2

• Chest x-ray
• Electrocardiogram
• Echocardiogram
• Spirometry