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kpmle2
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Topics: 53
Posts: 354

08/12/07 - 09:15 AM

A 46-year-old woman is brought to the emergency room 1 hour after she developed dyspnea and retrosternal pain of sudden onset. Her past medical history is remarkable for pulmonary thromboembolism 5 months ago, treated with warfarin. She is agitated, her skin is clammy, and her neck veins are distended. Vital signs are, PR: 130/min, BP: 80/40 mm Hg, RR: 35/min, Temperature 36.6C(97.9F). Heart sounds are somewhat muffled, without murmurs and rubs. Lungs are clear to auscultation. She is transferred immediately to the ICU. A central venous line and Swan-Ganz catheter are placed. The pressure readings are: right atrial pressure (RAP) 19, pulmonary artery pressure (PAP) 35/19, and pulmonary capillary wedge pressure (PCWP) 22. A chest x-ray shows widening of the mediastinum. Ultrasound is negative for pericardial fluid. Meanwhile, cyanosis and cervical ecchymoses are developing. What is the most likely diagnosis in this patient?

A. Pericardial tamponade
B. Restrictive pericarditis
C. Pulmonary thromboembolism
D. Mediastinal hemorrhage
E. Superior vena cava syndrome

cirus
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Topics: 108
Posts: 740

08/12/07 - 09:50 AM

D--> mediastinal hge

gr8doc
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Posts: 210

08/12/07 - 11:47 AM

Well, the mediastinal widening goes in the favor of Mediastinal H'ge but otherwise it could very well be a Pulmonary Thrombo Embolism.
I tried to look for the PCWP values in a case of PE but could not find it anywhere.Also, is there a mediastinal widening in a case of PE ? If we get the answers for these two, may be we can tell what it is .
What is the rt answer given?

Ivonne
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Topics: 57
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08/12/07 - 06:23 PM

Let see
1.-distended neck veins
2.-HR 130
3.-BP 80/40
4.-RR 35
5.-heart sounds somewhat muffled
6.-Clear lungs
7.-RAP&PAP 19, ^PCWP 22
8.-widened mediastinum
9.-No pericardial fluid

seems to be Mediastinal hemorrhage

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Justice
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Topics: 107
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08/12/07 - 08:11 PM

D. Mediastinal hemorrhage
Key word is cervical ecchymoses

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gr8doc
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Topics: 8
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08/12/07 - 08:40 PM

ok, can anyone please explain the cardiac cath pressures ?
And also, Mediastinal hemorrhage from which vessel?

Justice
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08/12/07 - 10:49 PM

gr8doc wrote:
ok, can anyone please explain the cardiac cath pressures ?
And also, Mediastinal hemorrhage from which vessel?

It is impossible to say from what vessel without MRI or mediastinoscopy… Just note that the Pt is on warfarin…

As for the mech-m of the cardiac chambers pressure: blood might accumulate around heart and compress it from outside thereby limiting compliance of ventricles that ultimately results in equalization of intachamber pressures in left and right heart…

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gr8doc
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08/13/07 - 11:30 AM

Thanks for enough Justice !!!!! smiling face

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