Graves Induced Reversible LVOT Obstruction

A 59-year-old male with a past medical history of obesity (BMI=31), controlled hypertension (HTN) and hyperlipidemia (HLD), presented for evaluation of new exertional dyspnea of three weeks duration. He reported difficulty climbing one flight of stairs in his house; six months ago he was able to exercise without limitations. He also complained of palpitations which he described as intermittent, regular and fast“heart pounding” both at rest and with activity. He denied chest pain, dyspnea at rest, orthopnea, paroxysmal nocturnal dyspnea, edema and syncope. Review of systems was also significant for 29 lbs of unintentional weight loss in the past six months confirmed by office weight record (199to 176lbs), generalized fatigue, mild hand tremor and insomnia. On physical exam his vital signs were within normal limits. He was noted to have mild exophthalmos as well asa new harsh 3/6 systolic murmur best heard at the 2nd right intercostal space. The murmur was intensified by having the patient stand up. His exam was otherwise unremarkable.