Right heart catheterization would provide additional hemodynamic information including cardiac output, filling pressures, and central venous pressure however, it is not routinely indicated in new diagnosis of heart failure. Chest radiography demonstrated new mild cardiomegaly. An electrocardiogram (ECG) showed atrial fibrillation with rapid ventricular response (RVR) at rate of 148 beats per minute (bpm) without ST-T segment changes suggestive of ischemia. His laboratory studies were the following: hemoglobin, 16.0 g/dL sodium, 143 mmol/L creatinine, 1.2 mg/dL low density lipoprotein, 77 U/L high density lipoprotein, 54 mg/dL, triglycerides, 88 mg/dL total cholesterol, 137 mg/dL thyroid stimulating hormone (TSH), 2.0 mlU/L. Although constrictive pericarditis can manifest with jugular venous distension and chest discomfort in the flat position, he does not have pleuritic chest pain, fever, or a friction rub on physical examination. ![]() The progressive nature of dyspnea is less consistent with pulmonary embolus or an acute coronary syndrome. He also has physical examination findings of bibasilar crackles, pitting edema, and abdominal distension. Patients with volume overload secondary to CHF often demonstrate dyspnea on exertion, weight gain, orthopnea, and paroxysmal nocturnal dyspnea. His symptoms are consistent with a classic presentation of CHF. There is no history of smoking and no wheezing on physical examination. The clinical findings are not suggestive of chronic obstructive pulmonary disease. On physical examination, he was tachycardic with a heart rate of 148 beats per minute with an irregularly irregular rhythm, bibasilar crackles, abdominal distention, jugular venous distension, hepatojugular reflux, and 1+, symmetric, bilateral lower extremity pitting edema. In terms of family history, he has a brother with a history of atrial fibrillation otherwise, there was no family medical history of heart failure or premature coronary artery disease. He never used tobacco products and reported an average alcohol intake of 2 to 3 beverages per week. His only medication included fexofenadine. His medical history was notable for a small, congenital ventricular septal defect (VSD), obesity (body mass index, 35 kg/m 2) and seasonal allergies. He had no recent upper respiratory illness symptoms, such as nasal congestion, sore throat, cough, or sinus pain. He denied fevers, chills, night sweats, palpitations, lightheadedness, or dizziness. He also noticed a decline in exercise tolerance from a prior ability to ascend 9 flights of stairs to tolerating only a few steps. ![]() He described his dyspnea as a feeling of “breathing through a straw.” Additional symptoms included a weight gain of 5 kg in the prior 3 weeks, increased abdominal girth, and paroxysmal nocturnal dyspnea. ![]() A 50-year-old man presented to his primary care provider with a 2-week history of progressively worsening dyspnea on exertion and chest discomfort while in the flat position.
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