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Young Man with Recent Onset Hypertension and Acute Onset Dyspnea

Reviewed By Behavioral Science Assembly

Submitted by

David Horne, MD

Senior Pulmonary Fellow

University of Washington

Seattle, Washington

Michael S. Mulligan, MD

Associate Professor of Surgery

University of Washington

Seattle, Washington

Christopher H. Goss, MD, MSc

Associate Professor of Medicine

University of Washington

Seattle, Washington

Submit your comments to the author(s).


The patient is a 31-year-old man with a history of anxiety, depression, and recent onset hypertension who presented to the emergency department with tachycardia, chest pain, and hypoxia. He was seated when he felt the abrupt onset of palpitations. He checked his pulse and found it was over 150 beats/min. In the emergency department, he was dyspneic and described chest pressure. The patient had noted dyspnea on exertion prior to this acute event. He also noted a non-productive cough, night sweats, and right lower quadrant pain. Over the last 2 months, the patient had noted generalized weakness and malaise with easy fatigability. He denied any recent weight loss. He denied any recent travel, trauma, or surgery. He drank alcohol socially and has smoked marijuana daily for 3 months. His family history is significant for a pulmonary embolus in his maternal grandfather, myocardial infarction at age 41 and three-vessel coronary artery bypass graft surgery in his father, and lymphoma in his maternal uncle.

Medical History:
Gastroesophogeal reflux disease
Depression and anxiety
Scalp alopecia

Physical Exam

The patient was a mildly tachypneic young man in no acute distress. He had no fever, a heart rate of 80 beats/min, a blood pressure of 123/79 mm Hg, and respiratory rate of 16 breaths/min. Oxygen saturation was 91 to 92% while breathing room air, and this increased to 94% on nasal cannula oxygen at 3 L/min. His neck veins were not elevated. His lung exam revealed decreased breath sounds on the right compared with the left, but no rales nor rhonchi. His cardiac exam revealed no murmur, rub, or gallop. He did have a physiologically split S2 heart sound. His abdominal exam revealed no hepatosplenomegaly, but he was tender to palpation in the right lower quadrant. His testicular exam was unremarkable. His skin exam was notable for diffuse raised thickened plaques on his scalp with patchy alopecia. His extremities were cool but well perfused. He had shotty groin adenopathy.

Empiric heparin for pulmonary embolism was started.


  • Complete Blood Count: white blood cell count 7,600/mm3, hemoglobin 13.5 g/dL, hematocrit 40%, platelets 241,000/mm3
  • Electrolytes and liver function tests were within normal limits, including creatinine of 1.0 mg/dL
  • Coagulation: Prothrombin Time 13.3 sec, International Normalized Ratio 1.1
  • Urine Analysis: negative for protein, blood, red blood cells or white blood cells
  • D-dimer: negative
  • Portable chest radiograph: No parenchymal infiltrates, no effusions, normal cardiac silhouette
  • Electrocardiogram: Normal, without evidence of right ventricular hypertrophy or strain. No ischemic changes were noted.
  • Echocardiogram: Left ventricular function was hyperdynamic, estimated ejection fraction was 70%, right ventricular function was normal, but hyperdynamic, mild to moderate tricuspid regurgitation, but otherwise normal valves.


Computed tomography angiogram of the chest with intravenous iodinated contrast

Question 1

What is the most likely diagnosis?


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