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A 66-Year-Old Man Comes to the Office for Evaluation of Progressive

question 543

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A 66-year-old man comes to the office for evaluation of progressive shortness of breath for the past 2 months. The patient used to walk nearly a mile a day without difficulty. More recently, however, he feels "out of breath" and tires easily after walking a few blocks. The patient has gained 4 kg (8.8 lb) over a similar period. He has also had a persistent, dry cough that is worse at night when he is lying in bed. The patient has had no fever, chills, or night sweats. He has a history of hypertension. He is a former smoker who quit 5 years ago. Until 4 years ago, the patient worked as an engineer at a local steel mill. Temperature is 36.1 C (97 F) , blood pressure is 154/90 mm Hg, pulse is 92/min and regular, and respirations are 20/min. Pulse oximetry is 94% on room air. BMI is 47.4 kg/m². The lungs are clear on auscultation. S1 and S2 are normal, and the point of maximal impulse is not palpable due to the patient's body habitus. The abdomen is soft and nontender. There is 1+ pretibial edema bilaterally. Initial complete blood count and complete metabolic panel are unremarkable. B-type natriuretic peptide is 95 pg/mL (normal: 100-400) . ECG shows normal sinus rhythm with evidence of left atrial enlargement. Chest x-ray is shown in the exhibit. $A 66-year-old man comes to the office for evaluation of progressive shortness of breath for the past 2 months. The patient used to walk nearly a mile a day without difficulty. More recently, however, he feels out of breath and tires easily after walking a few blocks. The patient has gained 4 kg (8.8 lb) over a similar period. He has also had a persistent, dry cough that is worse at night when he is lying in bed. The patient has had no fever, chills, or night sweats. He has a history of hypertension. He is a former smoker who quit 5 years ago. Until 4 years ago, the patient worked as an engineer at a local steel mill. Temperature is 36.1 C (97 F) , blood pressure is 154/90 mm Hg, pulse is 92/min and regular, and respirations are 20/min. Pulse oximetry is 94% on room air. BMI is 47.4 kg/m<sup>2</sup>. The lungs are clear on auscultation. S1 and S2 are normal, and the point of maximal impulse is not palpable due to the patient's body habitus. The abdomen is soft and nontender. There is 1+ pretibial edema bilaterally. Initial complete blood count and complete metabolic panel are unremarkable. B-type natriuretic peptide is 95 pg/mL (normal: 100-400) . ECG shows normal sinus rhythm with evidence of left atrial enlargement. Chest x-ray is shown in the exhibit. Echocardiography reveals concentric left ventricular hypertrophy, left atrial enlargement, and a left ventricular ejection fraction of 60%. Which of the following is the most likely cause of this patient's current symptoms? A) Chronic obstructive pulmonary disease B) Deconditioning C) Heart failure with preserved ejection fraction D) Interstitial lung disease E) Obesity hypoventilation syndrome$ Echocardiography reveals concentric left ventricular hypertrophy, left atrial enlargement, and a left ventricular ejection fraction of 60%. Which of the following is the most likely cause of this patient's current symptoms?

Definitions:

Phagocytic White Blood Cells

White blood cells that protect the body by ingesting harmful foreign particles, bacteria, and dead or dying cells.

White Blood Cell

Leukocyte; a blood cell with a role in housekeeping and defense. Lymphocytes are a special category of white blood cells that carry out adaptive immune responses.

Antigen-Presenting Cell

Immune cells that process and present antigens to T-cells, initiating an immune response by showing them what to attack.

Dendritic Cell

A type of immune cell that presents antigens to T cells, initiating an adaptive immune response; pivotal in mediating immunity and tolerance.