C16) Dyspnea on exertion in a patient with history of MI

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

  1. Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with hypoxia.
  2. Review the DDx considerations in a patient with hypoxia.
  3. Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with hypoxia.


Physical Exam


Provisional Diagnosis

Select the Dx you believe is most appropriate
The patient likely has CHF considering history of ischemic heart disease and other risk factors (T2DM, and male sex). The physical examination findings suggest CHF (cardiomegaly, S3 gallop) with both left (pulmonary edema, paroxysmal nocturnal dyspnea, orthopnea) and right (ascites, hepatomegaly, pitting edema, elevated JVP) sided involvement.
Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

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This patient is not at risk for immediate decompensation. However, they require further workup.

First Imaging Study

What is the first imaging study you will order?

A chest x-ray may rule out other pulmonary causes of dyspnea.
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Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

Watch our video

View the full study if you'd like to take a look yourself.

Second Imaging Study

What is the next imaging study you will order?

The current clinical picture is highly consistent with CHF. Chest CT is unlikely to provide any additional helpful information.
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What is your Diagnosis now that you have seen the imaging results?

Once the diagnosis is confirmed, the patient would be classified into NYHA II CHF as they have symptoms with ordinary physical activities. (NYHA I: no symptoms; III: symptoms during less than ordinary physical activity, IV: symptoms at rest.)

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

This patient is not at risk for immediate decompensation but requires further workup.

Assessment and Plan

Please provide your assessment and plan for this patient

54-year-old male presenting with signs, symptoms, labs, and imaging consistent with CHF. An echocardiogram will be obtained and cardiology will be consulted. A diuretic trial will be administered. The patient will benefit from further laboratory workup to rule out comorbidities and contributing etiologies.

Lessons Learned:
- Chest x-ray findings for CHF include (1) cardiomegaly (2) pulmonary vascular congestion and cephalization of the pulmonary veins, (3) pulmonary edema (interstitial edema and later alveolar edema; Kerley B lines; peribronchial cuffing, (4) and pleural effusions.

Socioeconomic Factors: Patients who may not closely follow up with their PCP should be counseled extensively on their disease and the required dietary and lifestyle modifications prior to discharge. 

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