Under Pressure

A CLINICAL PROBLEM-SOLVING article by Michael Detsky from University of Toronto, Canada.
A 25-year-old woman presented with dyspnea. She described a 2-year history of progressive shortness of breath on exertion. One year earlier she was able to walk on flat ground for approximately 5 minutes or walk up one flight of stairs. Within the previous 3 days, her condition had deteriorated to the point that she was unable to leave her bedroom without having dyspnea. The patient reported a nonproductive cough, palpitations, and pain on the left side of the chest that worsened with inspiration. Her medical history included unprovoked deep-vein thrombosis in the right leg. Her only current medication was warfarin.
On physical examination, the patient appeared to be in moderate respiratory distress. Her heart rate was 94 beats per minute and regular; her blood pressure was 110/64 mm Hg with no pulsus paradoxus. Respiratory examination revealed equal bilateral breath sounds, with no wheezes or crackles. A cardiovascular examination revealed a jugular venous pressure 10 cm above the sternal angle, with a positive Kussmaul's sign. There was a left-sided parasternal heave. The patient had a normal S1 sound and a loud, split S2, with no S3 or S4 sounds and no murmurs. There was no peripheral edema.
This case underscores the range of potential causes of pulmonary hypertension. [Original Article]