Running From Her Past

Information about a real patient is presented in stages (boldface type) to an expert clinician (Dr John R. Teerlink), who responds to the information, sharing his or her reasoning with the reader (regular type). A discussion by the authors follows. A 51-year-old woman presented to the emergency room with progressive dyspnea on exertion. She was an avid runner, and had completed a half-marathon 2 months before presentation. Since then, she had experienced a rapid decline in exercise capacity such that, on presentation, she was unable to climb a flight of stairs without stopping to catch her breath. She had recently completed a course of azithromycin prescribed by her primary care physician without benefit. She denied chest pain, lower extremity swelling, fevers, chills, or cough. She had had stage II left breast adenocarcinoma successfully treated 2 years before with Adriamycin-containing chemotherapy, radiation to the left chest, and bilateral mastectomy. Her only medication was fexofenadine for seasonal allergies. She had no previous heart disease or cardiovascular risk factors, with the exception of a distant 10–pack-year smoking history. She had no family history of premature cardiovascular disease. There was no history of illicit substance abuse. Dr John R. Teerlink: The differential diagnosis for rapidly progressive dyspnea on exertion includes cardiac, pulmonary, rheumatologic, and hematologic disorders. The notable aspects of the patient's history include her dyspnea on exertion in the absence of any other symptoms and her previous vigorous exercise capacity, which suggests a rapidly progressive process. Her previous breast cancer and associated treatment raises the possibility of Adriamycin-induced cardiomyopathy, radiation-induced coronary artery disease or constrictive pericarditis, or pulmonary embolus.On examination, the patient was comfortable but tachypneic. Her temperature was 36.6°C and her blood pressure was 112/73 mm Hg. Her heart rate was 100 bpm with a respiratory rate of 22 breaths per …