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Exertional dyspnoea and abnormal chest radiography

BMJ 2009; 339 doi: (Published 05 August 2009) Cite this as: BMJ 2009;339:b2920
  1. Luis Corral-Gudino, internal medicine consultant1,
  2. Ramón J Jorge-Sánchez, internal medicine consultant1,
  3. María Borao-Cengotita-Bengoa, internal medicine trainee1,
  4. Judit García-Aparicio, internal medicine consultant 1,
  5. Manuel Cascón-Bueno, cardiology consultant2
  1. 1Department of Internal Medicine, Hospital los Montalvos, Hospital Universitario de Salamanca, 37192, Salamanca, Spain
  2. 2Department of Cardiology, Hospital Universitario de Salamanca, 37007, Salamanca, Spain
  1. Correspondence to: L Corral-Gudino lcorral{at}

    A 75 year old woman was admitted to hospital because of dyspnoea. She had been well until nine months previously, when she started to have gradually worsening exertional dyspnoea. On admission, her physical activity was limited. She had no discomfort at rest, but even a very low level of activity caused dyspnoea. She reported no chest pain, orthopnoea, or paroxysmal nocturnal dyspnoea. She had a history of systemic hypertension. She denied smoking. Physical examination showed that she had tachypnoea and a tricuspid systolic murmur. Lung sounds were normal. Electrocardiography showed right axis deviation, right ventricular hypertrophy, and atrial fibrillation. Laboratory evaluation showed polycythaemia. Examination of her chest radiograph at admission provided clues to the diagnosis (fig 1).

    Fig 1 Chest radiograph


    • 1 What does the posteroanterior radiograph show?

    • 2 What can cause this finding?

    • 3 What should be the next test to confirm the suspected diagnosis?

    • 4 What further investigations are needed?


    Short answer

    • 1 The radiograph shows enlargement of the central pulmonary arteries, with attenuation of the peripheral vessels, suggestive of pulmonary hypertension (fig 2).

    Fig 2 Patient’s chest radiograph showing enlargement of the central pulmonary arteries (arrowheads), with attenuation of the peripheral vessels (arrows)

    • 2 Pulmonary hypertension can be associated with pulmonary arterial hypertension, either idiopathic, familial, or associated (with collagen vascular disease, left to right intracardiac shunts, portal hypertension, HIV infection, anorectic drugs, stimulants, or pulmonary venous obstruction); left heart disease; lung diseases or hypoxia; chronic thrombotic or embolic disease; and other diseases such as sarcoidosis or compression of pulmonary vessels.

    • 3 Transthoracic echocardiography is the preferred non-invasive screening test to estimate pulmonary artery systolic pressure.

    • 4 Non-invasive diagnostic tests include ventilation-perfusion scanning, pulmonary function tests, overnight oximetry, serology (liver function tests, HIV screening, antinuclear antibody tests), and the six minute walking test. Invasive right …

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