Noah

CTP is not the best at identifying subtle parenchymal changes, but we do have a normal CTP.

Going back to the Spiro, it's pretty interesting that she has an isolated

severe decreased DLCO, and that is an early clue of a vascular problem being present.

Other causes of low DLCO would be kind of a restrictive, would also cause a restrictive pattern on the spiral, like ILDs.

So I think the DLCO kind of points towards pulmonary hypertension, even in the spirometry.

So with the calf, now we have elevated mean pulmonary arterial pressure, which diagnoses this patient as broadly pulmonary hypertension.

We have a normal wedge, which basically says that the left-sided pressures are fine, and we have increased resistance.

This would be compatible to me to a pre-capillary pulmonary hypertension.

So that's how I'm labeling this patient in my mind.

What do you think, Yusuf?

I love PAPI, by the way.

Yeah, I really like the PVOD hypothesis.

I was thinking about it before with the diffuse DLCO and the cryptic hypoxia.

It would be

The decreased DLCO in pulmonary hypertension can be from a problem in diffusion or from reduced blood flow and severe pH.

In this case, it seems like the hypoxia predated the pH.

And the etiology that causes severe hypoxia is PVOD, because you have the disruption of the gas exchange through proliferation of the alveolar membrane.

And the classic manifestation of the EPO, it's kind of suggestive.

I think it can cause either hemodynamic instability or pulmonary edema.

And I'm excited to see what else you have in store for us, Maddie.