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 - 11:45 AM
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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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| young_doc
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Well the CO has absolutely nothing to do with PO2..
But you're right, cardiogenic Pulmonary Edema can cause hypoxia. But like i said earlier, in CHF, it's initially only the lung bases that are affected, and NOT "all lung fields"...?
It's easy to argue both ways.. there are clues for PE as well as for CHF.. but in my opinion, in this case the most likely answer is PE.
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| doc-o8
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hey guys y cant it be E. can be pulmonary edema secondary to CHF. its nt temponade n PE should have clear lungs. ???
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| dr19
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Pulmonary Embolism
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| dr in trouble
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you can find diffuse crackles in massive PE as well as S3 in 30% of cases.
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| doc-o8
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ya now i understand its pulmonary embolism. she also has thrombocytosis favouring that. n just read that chf can also cause pulmonary embolism. hehehe
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| arlete
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Chronic CHF (which she does not have) may cause PE.
Normal platelet values: 150,000 - 400,000, therefore, she does not have thrombocytosis.
I've been reading, yes, it could be PE as well. Good question!
Edited by arlete on 07/15/07 - 07:08 AM
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| alexaE
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its pulmonary embolism... straight forward question!
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| radonc
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I apologise that my explanation is rather lacking, DeltaF508. I do realise that RV failure does NOT result in pulmonary oedema. So, my explanation is deficient.
But my answer is still pulmonary oedema. Massive PE DOES cause acute congestive heart failure. How? I am not so sure, but I am sure that it can. The best answer for the question is still PE; you can argue for or against it, but the clinical picture fits best with a PE.
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| doyoudig
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guys pls check out the 2 nbme questions, for comparison
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| radonc
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Now, I am starting to think the answer (to the question of the elerly lady with acute SOB) may be CHF, of uncertain cause.
The answer to the other question (the elderly man with acute SOB) is PE. That's the best fit to this set of two questions.
What do others think?
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| virgola82
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I answered PE and I am pretty confident that's the right answer...
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| DeltaF508
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I think it's PE as well; the more I read PE, the more I am convinced.
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| radonc
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So it's PE for both questions??? But it's so unstylish 
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| ssrpk
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people going in favor of pericardial tamponade....can any one of you please asnwer what could lead to pericardial tamponade in an otherwise healthy individual , just like that???
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| dr in trouble
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Idiopathic causes--------Vasculitis i guess
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