Right-to-Left Shunt

The patient is a 25-year-old woman transferred to Hermann Hospital 3 days after admission to an outlying facility. The patient initially woke up at 3 AM with acute onset of nausea, mild headache, hemoptysis (1⁄4/4 cup of fresh blood), and worsening shortness of breath. She then noticed weakness in the right half of her body associated with dysarthria. She had no associated chest pain or palpitations. In the past, she had experienced recurrent episodes of transient weakness of her limbs on the right side and one episode of transient left hemianesthesia. None of the episodes were associated with any permanent sequelae, and she had not sought medical attention for them. She had a history of asthma since childhood worsened by mild to moderate exertion, for which she used a Ventolin inhaler. She denied a history of cyanotic spells, squatting, or syncopal episodes. She did describe a history of intravenous drug abuse (cocaine) and alcohol abuse until 5 years before admission. She smoked one pack of cigarettes per day for the past 10 years. Over the past 2 to 3 years, she described occasional episodes of epistaxis.