MKSAP: 61-year-old woman with progressive dyspnea and fatigue

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. A 61-year-old woman is evaluated for a 4-month history of progressive dyspnea and fatigue without chest pain. Eighteen months ago, she was diagnosed with liver cirrhosis due to nonalcoholic steatohepatitis (NASH). Medical history is also significant for obesity. Medications are propranolol, spironolactone, and lactulose. On physical examination, temperature is 36.4 °C (97.5 °F), blood pressure is 112/64 mm Hg, pulse rate is 60/min, and respiration rate is 16/min; BMI is 36. Mild scleral icterus is noted. Cardiac examination reveals a prominent S2. The lungs are clear. Dilated veins are visible on the trunk and abdomen, and there is no appreciable ascites. Trace symmetric ankle edema is noted. Chest radiograph shows cardiomegaly and clear lung fields. Pulmonary function tests show normal spirometry but reduced diffusing capacity (42% of predicted). A resting echocardiogram shows a left ventricular ejection fraction of 70% and an estimated right ventricular systolic pressure of 58 mm Hg. No shunt is seen with contrast enhancement. A dobutamine stress echocardiogram is negative for ischemia. A ventilation-perfusion scan shows a low probability of pulmonary embolism. Right heart catheterization reveals a mean pulmonary artery pressure of 48 mm Hg and a pulmonary capillary wedge pressure of 12 mm Hg. Which of the following is the most likely diagnosis? A: Chronic thro...
Source: Kevin, M.D. - Medical Weblog - Category: Journals (General) Authors: Tags: Uncategorized Source Type: blogs