Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for follow-up of CTD-associated PAH secondary to systemic sclerosis. Reports progressive exertional dyspnea (NYHA Class [I/II/III/IV]), fatigue, and reduced exercise tolerance. Denies syncope, pre-syncope, or chest pain. No recent orthopnea or PND. Current SSc symptoms include Raynaud’s phenomenon, digital ulcers, and GERD. Adherent to PAH-specific pharmacotherapy.
Clinical Examination Findings
Vitals: Stable, O2 sat [X]% on RA. General: No acute distress. CV: Regular rate and rhythm, loud P2, grade [X]/6 holosystolic murmur at the left sternal border (consistent with tricuspid regurgitation), no S3/S4. Resp: Clear to auscultation bilaterally, no crackles. Ext: Sclerodactyly present, no peripheral edema, capillary refill <2 seconds. Skin: Tightening of skin over fingers and face noted.
Treatment Protocol
Continue current PAH-targeted therapy: [Medication Name/Dose]. Monitor for side effects including peripheral edema, headache, or flushing. Maintain strict adherence to SSc management (e.g., CCBs for Raynaud’s, PPIs for GERD). Repeat 6-minute walk test (6MWT) and NT-proBNP in [X] weeks. Follow-up echocardiogram scheduled for [Date].