Treating a 47 Year-Old Male With Lymphoma and Shortness of Breath

History of Present Illness:
A 47-year-old male complains of mild progressive shortness of breath. He was admitted three days previously for a second cycle of scheduled R-CHOP (rituximab, cyclophosphamide, hydroxydaunorubicin, oncovin, prednisone) therapy for recently diagnosed Non-Hodgkin Lymphoma. The patient had tolerated his first round of chemotherapy approximately one month ago well without major complications. A surface echocardiogram performed prior to this admission showed normal left ventricular systolic function (estimated LV ejection fraction >55%).

Past Medical History:
Non-Hodgkin Lymphoma (recent diagnosis)
Type II Diabetes Mellitus (diet-controlled)
Gastroesophageal Reflux Disease

Hydrochlorothiazide 25 mg orally once daily
Simvastatin 20 mg orally at bedtime
Phenergan 12.5 mg orally every 6 hours as needed for nausea

Physical Examination:
Vital Signs – Temp 99.2 degrees F, HR 90 beats per minute, BP 106/76 mmHg, RR 16 breaths per min, O2 sat 93% on 1L oxygen by nasal cannula

HEENT – Pupils are equal and reactive. Oropharynx is clear.
Neck – Supple with no lymphadenopathy.
Cardiac – JVP estimated at 11 cm. Normal rate and regular rhythm. No murmurs, rubs, gallops, or heaves.
Respiratory – Bilateral rales without rhonchi or wheezes. Fair air movement bilaterally.
Abdominal – Soft, obese, non-distended, and non-tender to palpation.
Musculoskeletal – No joint or muscular deformities.
Extremities – No cyanosis or clubbing. Trace lower extremity edema bilaterally.

Pertinent Social History:
Patient is a 20 pack-year smoker.

Laboratory Data:
Complete blood count and basic metabolic panel are within normal limits.
BNP 520 pg/mL
Troponin-I 0.16 ng/mL
CK 202 units/L
CK-MB fraction 3.6 ng/mL


Electrocardiogram: Treating a 47 Year-Old Male With Lymphoma and Shortness of Breath

Surface Echocardiogram:

Parasternal Long Axis (Clip 1)

Parasternal Short Axis (Clip 2)

Apical Four Chamber (Clip 3)

At this point, what would be your next management step?

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