Question

A 69-year-old man presents with dyspnea on exertion that has been slowly progressive over the course of the last year. He notes impairment in climbing stairs and walking short distances. His review of systems is positive for fatigue, palpitations, intermittent retrosternal chest pain, swelling of his lower extremities, dizziness, and "feeling faint;" his associated symptoms are also known to occur upon exertion. He denies any fever, chills, weight changes, cough, abdominal pain, early satiety, nausea, vomiting, diarrhea, changes to his urine color or odor, flank pain, hematuria, or dysuria. He denies any cigarette, alcohol, or drug use. His cardiac exam is remarkable for an increased pulmonic component of the second heart sound (P2), wide, inspiratory splitting of S2 over the cardiac apex, right-sided S3 and S4 gallops, a left parasternal lift, a loud diastolic murmur that increases with inspiration and diminishes with the Valsalva maneuver, prominent "A" waves in jugular venous pulsations, and increased JVD. He has an enlarged liver with hepatojugular reflux, peripheral edema, and ascites. A bedside EKG analysis revealed peaked P waves, rightward axis deviation, and prominent R waves in the early V leads.

What is the most likely diagnosis?

1. Myocardial infarction
2. Cor pulmonale
3. Primary biliary cirrhosis
4. Left ventricular heart failure
5. Pulmonary embolism

Answer 1

The most likely diagnosis is Cor pulmonale, indicated by symptoms and cardiac exam findings suggestive of right heart failure and EKG abnormalities consistent with right atrial enlargement and right ventricular hypertrophy.

Step-by-step explanation:

The most likely diagnosis for a 69-year-old man presenting with progressive dyspnea on exertion, fatigue, palpitations, retrosternal chest pain upon exertion, lower extremities swelling, dizziness, and "feeling faint" is Cor pulmonale.

The cardiac exam findings suggest right heart failure, evidenced by an increased pulmonic component of the second heart sound (P2), wide inspiratory splitting of S2, right-sided S3 and S4 gallops, a left parasternal lift, and a loud diastolic murmur that changes with respiration and position.

These signs, along with prominent "A" waves in jugular venous pulsations, increased jugular venous distention (JVD), hepatomegaly with hepatojugular reflux, peripheral edema, and ascites, support the diagnosis of cor pulmonale which is right ventricular hypertrophy secondary to a lung disorder that causes pulmonary artery hypertension. The EKG findings with peaked P waves, rightward axis deviation, and prominent R waves in the early V leads are indicative of right atrial enlargement and right ventricular hypertrophy.