Duncan I: Short of Breath

Cardiovascular System

{"ops":[{"insert":"Clinical Reasoning"},{"insert":"\n","attributes":{"header":1}},{"insert":"Decision 1: Investigation of heart failure"},{"insert":"\n","attributes":{"header":2}},{"insert":"Duncan has presented with progressive painless swelling of both legs, worsening fatigability, exertional dyspnea, and paroxysmal nocturnal dyspnea. He suffered a ST-elevation myocardial infarction (STEMI) just an year ago and has defaulted on treatment since. Examination reveals bilateral pitting peripheral edema, cardiomegaly, a fourth heart sound, and bibasal crackles. Considered together, these finding are suggestive of heart failure, likely secondary to the past STEMI.\n\nHis evaluation should continue with an ECG and echocardiogram, at a minimum. Cardiac enzymes are not justified currently, as there are no signs or symptoms suggestive of acute ischemia. While brain natriuretic peptide (BNP) levels are a sensitive and specific biomarker f"}]}

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