Pulmonary Hypertension: The Daily PANCE Blueprint
A 35-year-old woman comes to the clinic due to progressive shortness of breath over the past year. She reports being unable to walk more than a block without stopping to rest. On physical examination, the pulmonary component of S2 is louder than the aortic component at the right and left second intercostal spaces. Additionally, a palpable impulse is noted along the left upper sternal border. A chest x-ray reveals clear lung fields. Which of the following conditions is most likely responsible for her symptoms?
A. Atrial septal defect
B. Pulmonary arterial hypertension
C. Mitral stenosis
D.. Congestive heart failure
E. Chronic obstructive pulmonary disease (COPD)
Answer and topic summary
The answer is B. Pulmonary arterial hypertension
Pulmonary arterial hypertension (PAH) is characterized by increased pressure in the pulmonary arteries. It commonly presents with exertional dyspnea and fatigue, which progressively worsen over time. The physical examination findings include a loud P2 (pulmonary component of the second heart sound) due to elevated pulmonary pressures and a palpable impulse along the left upper sternal border due to right ventricular hypertrophy. The clear lungs on chest X-ray further support this diagnosis as they suggest the absence of left heart failure or significant lung pathology.
Incorrect Answer Explanations:
- A. Atrial septal defect: An atrial septal defect (ASD) can cause a wide and fixed split S2 and may lead to right ventricular overload, but it typically does not cause a louder P2 or an accentuated impulse along the left upper sternal border in the absence of significant prior symptoms.
- C. Mitral stenosis: Mitral stenosis is associated with a low-pitched diastolic murmur best heard at the apex and often results in left atrial enlargement and pulmonary congestion, which would likely present as interstitial edema on a chest x-ray.
- D. Congestive heart failure: Congestive heart failure commonly presents with dyspnea but is usually accompanied by pulmonary congestion and edema visible on chest x-ray. The physical findings described are more suggestive of isolated pulmonary hypertension rather than overall heart failure.
- E. Chronic obstructive pulmonary disease (COPD): COPD usually presents with chronic cough, wheezing, and a history of smoking. The physical examination findings of a loud P2 and an accentuated left upper sternal border impulse are less typical of COPD and are more indicative of pulmonary hypertension.
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Smarty PANCE Content Blueprint Review:
Covered under ⇒ PANCE Blueprint Pulmonary ⇒ ⇒
Also covered as part of the Internal Medicine PAEA EOR topic list
