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Geroo
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03/09/07 - 01:48 PM       #1

29.) Ais admitted to the hospital because of progressive shortness of
breath for 10 days. He has a history of chronic venous stasis and deep venous
thrombosis. He has been treated with warfarin since he had several pulmonary
emboli 2 years ago; he takes no other medication. He has smoked two packs of
Cigarettes daily for 30 years. He weighs 109 kg (240 lb) and is 165 cm (65 in) tall.
Examination shows jugular venous distention. Echocardiography is most likely to
show which of the following?

A) Left ventricular dilation

B) Mitral stenosis

C) Pericardial thickening and tamponade

D) Right ventricular hypertrophy and dilation

E) Tricuspid stenosis


robin082006
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03/09/07 - 02:34 PM       #2

C) Pericardial thickening and tamponade


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Geroo
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03/09/07 - 03:09 PM       #3

why not d ?

robin082006
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03/09/07 - 03:12 PM       #4

Right ventricular hypertrophy and dilation has no SOB

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Geroo
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03/09/07 - 03:35 PM       #5

thanks robin

do u have answers key for form 2?


Aashi
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03/09/07 - 04:31 PM       #6

Hx of recurrent P.E----->secondary pul.HTN----->Right ventricular hypertrophy and dilation

Moreover warfarin use can lead to bleed within the pericardial sac----->acute tamponade and not a pericardial thickening-->this is something we see in constrictive pericarditis---->which doesnt suit the clinical scenario, This guy is not on warfarin currently , so we can r/o bleed cozed by warfarin use here, and since he is not on any anticoagulants he can go into pul.embolism again( coz of his hx)----->and we all do agree that the MC symptom in P.E is SOB---->probably this guy might have got a block in the main pul trunk----->putting a strain to the rt heart( SOB, inc JVP and clear lungs).. and so the only choice that makes sense here is ------> D

any other input is welcome

GLwink

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prasanthi
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03/09/07 - 04:42 PM       #7

i too agree with aashi

dr in trouble
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03/09/07 - 04:44 PM       #8

Is it possible that the pt. with occlusion of main pukmonary trunk come to emergency room after 10 days??????Isnt it an emergency condition????///

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Aashi
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03/09/07 - 04:54 PM       #9

PUL HTN is not an acute condition dr in trouble-->this also causes SOB-->if u read the hx they mention it was a PROGRESSIVE sob-->he is worse now and therefore he is presenting to the ER now..Rt ventricular Hypertrophy is also a chronic condition, not happened just within a day ...a guy with recurrent P.E --->secon Pul HTN-->rt ventricular Hypertrophy( this will be the ECHO finding), wether or not his main PUL.artery is blocked, echo or CT scan help,and yes that will be acute with hemodynamic instabilty but that doesnt r/o a rt ventricular hypertrophy which is due to his chronic hx---->and the only choice that suits the clinical scenario and the hx of the pt is -------> D

Hope u got the point now..Dr in trouble..and if you think some other choice in the q seems to be perfect, pls paste down a logical reasoning as well..we all can have a healthy discussion on that..

GLwink

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robin082006
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03/09/07 - 05:10 PM       #10

PE cannot explain JVD

This patient may have cancer (30 year smoking)->metastasis to pericardium---> temponade and pericadial thickening, also gradually increasing.

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Aashi
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03/09/07 - 05:28 PM       #11

Good thinking robin..smiling face..and yes i shld have supoorted that, if the pt had given some hx of wt loss( infact this guy is over wt), hemoptysis ,s/s of any paraneoplastic syndromes-->if he already throwing out mets like the way u mentioned,which is in advanced stages , i think they shld have atleast mentioned one symptom of CA in the hx..

Recurrent P.E--->PUl HTN--->Rt heart ventricular hypertrophy --->recurrent attack on a already decompensated heart-->and rt sided CHF--->current s/s--->and yes SOB may not be found in RHF.but a recurrent P.E can produce this MC symptom

S/S for constrictive pericarditis--->Tamponade->they shld have atleast mentioned abt the BECKS triad-->hypotension, JVP and muffled heart sounds-->pulses paradoxes, kausmauls sign , pericardial knock of constrictive pericarditis


GLwink

Edited by Aashi on 03/09/07 - 05:39 PM

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dr.shailu
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03/09/07 - 06:32 PM       #12

agree with aashi


its D






92306
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03/11/07 - 10:26 AM       #13

D) Right ventricular hypertrophy and dilation

PUl HTN



huyniid
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03/17/07 - 01:42 PM       #14

D. for both PE and smoking Hx









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