The Ever-Expanding Differential

A 74-year-old female patient with a history of breast cancer, aortic valve stenosis, type II diabetes mellitus, and hypothyroidism was referred to our institution for further evaluation of dyspnea and fatigue. She described progressively worsening dyspnea on exertion, which limited her to a few steps and required her to use a wheelchair at all times. Approximately 6 months prior to her current presentation, she was diagnosed with breast cancer, metastatic to the axial and appendicular spine. She was initiated on everolimus and exemestane along with opioids for pain management. During her current visit, a physical exam demonstrated an oxygen saturation of 84% on room air that improved to 95% with 2L nasal cannula, a soft S1 and a late peaking IV/VI systolic murmur heard best at the right upper sternal border without an A2, no lower extremity edema, and a normal jugular venous pressure. Mild diffuse mid- to end-inspiratory crackles were heard over all lung fields. Her laboratory results were notable for the following:

  • Hemoglobin = 8.4 g/dL
  • White blood cell = 9.8 x 109/L
  • Creatinine = 1.0 mg/dL
  • N-terminal pro-B-type natriuretic peptide = 6,000 pg/m
  • Thyroid-stimulating hormone = 0.3 mIU/L

A transthoracic echocardiogram demonstrated an aortic valve area of 0.65 cm2, mean gradient of 49 mmHg, and peak velocity of 4.4 m/s along with an ejection fraction of 53%. A computed tomography (CT) angiogram of the chest (Figures 1-2) was negative for pulmonary emboli but demonstrated interlobular septal thickening (red arrows), scattered nodular consolidative opacities (yellow arrows), bronchial wall thickening (green arrows), bilateral pleural effusions, and nodular changes of the right major fissure (blue arrow). Other findings included enlarged mediastinal and paratracheal lymph nodes.

Figure 1: CT Angiogram of the Chest in Transverse View at Presentation

Figure 1

Figure 2: CT Angiogram of the Chest in Coronal View at Presentation

Figure 2

Based on the clinical presentation, physical exam, and imaging findings, what is the next best step to improve this patient's dyspnea?

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