doyoudig
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A previously healthy 67-year-old woman is brought to
the emergency
department by paramedics 40 minutes after the sudden
onset of shortness of
breath while shopping. She is unable to provide
additional medical
history. She is in severe respiratory distress. Her
temperature is 37 C
(98.6 F), blood pressure is 90/60 mm Hg, pulse is
120/min and regular,
and respirations are 24/min. Examination shows marked
jugular venous
distention. Diffuse crackles are heard throughout all
lung fields.
Cardiac examination shows an enlarged point of maximal
impulse and normal
S1 and S2; there is an S3. Abdominal examination
shows no
abnormalities. There is no edema of the lower
extremities. Laboratory studies
show:
Hematocrit 38%
Leukocyte count 12,000/mm3
Platelet count 350,000/mm3
Arterial blood gas analysis on 5 L/min of oxygen:
pH 7.5
PCO2 16 mm Hg
PO2 64 mm Hg
A
) Acute gastrointestinal bleeding
B
) Adrenal insufficiency
C
) Aortic valve rupture
D
) Cardiac tamponade
E
) Congestive heart failure
F
) Pneumonia
G
) Pulmonary embolism
H
) Sepsis
pls give me a logic explanation from the findings for ur answer and how you r/o others
thx
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| tongsaa
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C??
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| dr in trouble
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I will say Pulmonary embolism .
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| elitoki
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I will go with Pulmonary Embolism. G.
As much I remember...
pte has CHF with S3, and with inability to exchange gases (pH 7.5, PCO2 16 mm Hg<
PO2 64 mm Hg) and physical exams of acute worsening of CHF with sudden onset...I'll go PE as diagnosis. 
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| DeltaF508
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It really is a hard question. I'll try to put in my 2 cents. Here’s my take on it: please let me know if it is wrong.
Answer is Pulmonary embolism (originally thought it was Tamponade, but the explanations in the posts below this one make more sense).
a) Acute GIB: would be seen on physical exam since would have to be pretty massive to have such an acute onset of symptoms; also JVD would not be present because you would be hypovolemic. Also you would not get diffuse crackles on lung fields, S3 and enlargement PMI (remember it says she was previously healthy).
b) Adrenal insufficiency: would present with Nausea, vomiting, abdominal pain, hypotension; she has Hypotension but none of the other features. Also I don’t believe there will be any respiratory findings like crackles on lung exam. JVD will also not be present.
c) Aortic valve rupture: lady is previously healthy but unable to provide medical history; she may have had endocarditis or rheumatic heart disease prior. However a murmur of aortic regurg would be heard on aortic rupture; she might develop CHF with edema and crackles on lung fields, as well as JVD. But she has severe hypotension, which would not be present; if anything she would have a wide pulse pressure.
e) CHF: again, this is an acute onset of symptoms; she has no lower extremity edema, no hepatomegaly; while she does have JVD and crackles in the lungs, she also has hypotension; mostly we see hypertension or normotension with CHF, correct?
f) Pneumonia: acute onset; no fever, no cough; hypotension, enlarged PMI and S3 are not regularly seen in PNA.
g) Pulmonary Embolism: originally I thought it might be PE; there is JVD in PE, but that doesn’t explain the S3, enlarged PMI and with PE, there usually is a clear lung, correct? Plus Hypotension is not seen unless it’s a massive PE (which it very well could be); however I think tamponade is a better choice.
h) Sepsis: acute onset, no fever; previously healthy; way down on the differential
Edited by DeltaF508 on 07/14/07 - 08:24 AM
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| doyoudig
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Thats a great explanation, I am impressed
but do have a question for u, what if the lady has Acute Onset of CHF, Biventricular Failure, which would not immediately cause developement of edema.
additionally, when CO decreases, there would normally be a compensatroy increase in SVR (Systemic Vascular R.) , would that not be the case in either CHF as well as Cardiac Tamponade since both causes Hypotension?
WBC is actually slightly increased,
S3 is a sign of a Dilated Heart, but could be a normal finding in Elderly
S1/S2 is normal so Cardiac Valve Rupture is unlikly and not the cause of CHF
I was thinking CHF but can't think of any cause, with the little Hx that is provided
pls let me know what els u think
thx
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| doyoudig
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just to add, Lung would be clear in Cardiac Tamp, which is akey different pint from Pulmonary edema. There should not be a backup problem as seen in Biventricular CHF but rather volume overall is low b/c of pressure on the entire heart
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| dr_arc
Forum Senior
Topics: 5
Posts: 156
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PE
hpoxemia and hypocapnea
acute gi bleed= picture of hypovolemic shock.
adrenal insuffuciency = total collapse.
aortic valve rupture= charecteristic auscultatory findings
tamponade= hypotension, JVP up, muffled heart sounds and clear chest
CHF = preexisting heart condition now pushed into failure
pneumonia= systemic and auscultatory features of infection
sepsis= fever, features of infection. def not sudden onset
previously healthy female with sudden onset SOB, gases showing hypoxemia and hypocapnea = massive PE
distended neck veins and other auscultatory findings by virtue of the very massive PE.
Edited by dr_arc on 07/14/07 - 08:11 AM
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| radonc
Forum Senior
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I think it's PE. Cardiac tamponade does not result in pulmonary oedema. PE results in pulmonary oedema by causing right ventricular failure.
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| DeltaF508
Forum Junior
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Can someone pls explain how right ventricular failure causes pulmonary edema; I thought there is no forward flow of blood; so there will be JVD and hepatomegaly and pedal edema, but how 'pulmonary' edema?
Thx
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| cirus
Forum Guru
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Can't be Pulm embolism--> Bilat crackles (in a previous healthy), Hypot & Inc JVD points to a cardiac cause.. So ill go with cardiac tamponade
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| cirus
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DeltaF508 wrote:
Can someone pls explain how right ventricular failure causes pulmonary edema; I thought there is no forward flow of blood; so there will be JVD and hepatomegaly and pedal edema, but how 'pulmonary' edema?
Thx
Due to increases left vent pr, back pressure on the pulm circulation leading to engorgment of vessels & extra vastion--> edema
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| DeltaF508
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But why would there be left ventricular pressure increase in Right ventricular failure? Isn't there a smaller amount of blood coming to the left ventricle? So there should be lower pressure, right?
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| cirus
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DeltaF508 wrote:
But why would there be left ventricular pressure increase in Right ventricular failure? Isn't there a smaller amount of blood coming to the left ventricle? So there should be lower pressure, right?
Right ventricular Failure with pulm edema is due to:
1. Left vent Failure--->pulm HTN---> rt vent failure
2. Pulmonary hypertention--> core pulmonale
i.e. Back pressure
Rt vent failur due to rt vent MI or Valve will not be associated with Pulmonary edema exept late dt to generalized CHF ( failure of all mech to overcome the rt sided hrt failure)
Hope that helps
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| doyoudig
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how are u ruling out CHF, as u said there is no Hx given, not even any Risk Factors for Pulm Embolism
This is sudden onset, but Cor Pulm develops progressively not suddenly
Also Exam shows DIFFUSE CRAkcles, I don;t think that diffuse id typical of PE
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| Justice
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Out of the choices only PE and PT can happen suddenly and give the above presentation... But for PE the pulmonary edema isn't specific whereas for PT it is... Plus enlarged point of maximal impulse... I go with (D)
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| cirus
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I'm not saying Core pulmonale or Pulmonary emb
I was bet Cardiac Tamponade & CHF, But the sudden drop of bl pr with the rise of JVD, made me go towrds cardiac tamp ( mb aortic bleedin), but i'm not sure
if anyone has any logical expl plz do
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| arlete
Intern in 2009!!!!!
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Acute CHF due to acute MI = E.
PE does not give you crackles + S3 + displaced apical impulse.
Cardiac tamponade gives you mostly right side signs of CHF and mufled heart sounds.
Cor pulmonale is a chronic condition and gives right side signs of CHF.
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| arlete
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Actually I would say acute cardiogenic pulmonary edema instead of CHF, but since we don't have that option...
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| doyoudig
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Cardiac Tamponade Has Clear Lung Fields. Muffled Heart Sounds...
PE - Does not invilves Parenchyma, hence will not see DIFFUSE Crackles Noramlly Lung Fileds are Clear, can hear rales/crackles but must be a chronic condition
She is Elderly probaly Acute MI -> Acute CHF, S3, Point of Impulse, DIFFUSE CRACKLES Heard thruout ALL Lung Fields, and since this is ACUTE, Lower Extremitiy Edema may not be seen yet
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| young_doc
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My 2 cents:
-not likely CHF. CHF is not something that occurs suddenly. And as for "MI leading to CHF" --> our patient doesn't even have chest pains! Also MI/CHF would not give the ABG values that we have here. Also in CHF we typically have a displaced PMI, and not an enlarged PMI.
-ALSO, CHF does NOT have "crackles in ALL lung fields", it has crackles at the lung BASES.
-Tamponade should have clear lung fields.
This answer is most likely a PE. If you argue against PE because there shouldn't be "diffuse crackles in ALL lung bases" in PE... well we shouldn't have that in Tamponade or CHF either!!!!!
If you argue that there shouldn't be hemodynamic instability, well that could be due to a massive embolus. (emedicine)
Enlarged point of maximum impulse does not necessarily mean CHF, as it can due to Aortic stenosis (common in elderly), or chronic anemia. I mean we have no past medical history.
Also, 34% of PE's will have S3 or S4 (emedicine).
All discussions are welcome  This is indeed a tough one!
Edited by young_doc on 07/14/07 - 01:45 PM
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| doyoudig
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youngdoc, can u pls tell me what ABG would be with CHf, thx much
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| hanwin
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This is PE. Hypoxia with repiratory alkalosis.
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| young_doc
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doyoudig wrote:
youngdoc, can u pls tell me what ABG would be with CHf, thx much
We could have hypocapnia in CHF due to the increased RR....but we don't typically have hypoxia in CHF.
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| doyoudig
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why not hypoxia, since CO will be reduced and Pulmonary edema interferes with normal Gas exchange hence PaO2 will be reduced
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