22 Jan A 72 year-old woman with a history of CHF presents with several weeks of gradually progressive dyspnea on exertion (DOE). At her baseline, she is able to
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Question: Does my patient have significant aortic stenosis?
A 72 year-old woman with a history of CHF presents with several weeks of gradually progressive dyspnea on exertion (DOE). At her baseline, she is able to walk several blocks, but now feels winded. She denies chest pain, palpitations, syncope/near syncope, cough, orthopnea, or PND. She states she is compliant with her medications and diet. She has had a recent functional study that showed minimal ischemia.
Meds
aspirin
digoxin 0.125 qd
lisinopril 20 mg qd
furosemide 20 mg qd
KCl 10 mEq qd
PE
HR 90, regular
PB 134/70
Labs
chem 7:
Na 132
K 5
Cl 94
HCO3 30
BUN 18
Cr 1.3
CBC: notable for Hgb 14 g/dL (Hct 43%)
CV
RRR, normal S1 and S2
No S3 but has S4
2/6 mid-peaking systolic murmur at the LUSB that radiates to the carotids.
PMI is mildly enlarged and sustained
Neck
Carotid pulse is brisk.
JVP flat
Positive abdominojugular reflux
CXR
Xray shows cardiomegaly and mild vascular redistribution
ECG
Unchanged with an incomplete LBBB pattern
Clinical Diagnosis
Worsening of her congestive heart failure (positive AJR, enlarged and sustained PMI, cardiomegaly, and vascular redistribution).
Clinical Questions
Is this patient's worsening CHF due to significant aortic stenosis?
Please elaborate why you think it may be aortic stenosis according to patient's symptoms and how do you assess each symptom.
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