dr19
Forum Senior
Topics: 12
Posts: 120
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A previously healthy 67-year-old woman is brought to the ER by paramedics 40 min. after the sudden onset of shortness of breath while shopping.She is unable to provide additional medical history.She is in severe respiratory distress.Temp.=37.0C,BP=90/60,
pulse=120,resp.=24/min.Examination shows marked jugular venous distention.Diffuse crackles are heard throughout all lung fields.Cardiac exam. shows an enlarged point of maximal impulse and normal S1 &S2;there is an S3.Abdom.examinatin shows no abnormalities.There is no edema of the lower extremities.Lab studies:
hematocrit:38%
Leukocyte count:12000/mm3
platelet count:350000/mm3
Arterial Blood Gas analysis on 5L/min O2:
pH:7.5
pCO2:16 mmHg
pO2: 64mmHg
A)acute GI bleeding
B)adrenal insufficiency
C)aortic valve rupture
D)cardiac tamponade
E)congetive heart failure
F)pneumonia
G)pulmonary embolism
H)sepsis
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| Miradautas Vras
Forum Elite
Topics: 13
Posts: 351
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D tamponade . confused among d/e. But since acute onset going for d
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| farnsworth
Forum Newbie
Topics: 0
Posts: 165
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G
(cardiac tamponade - muffled S1/S2)
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| guangyu
Forum Elite
Topics: 29
Posts: 308
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E( S3, diffuse crack in lung, jugular venous distension)
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| shahnaz.r
Forum Junior
Topics: 7
Posts: 77
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Probably G [Pulmonary embolism]?
Rule in points:
acue onset; hypotension; tachy; resp. distress with resp alkalosis;elevated JVP [can be seen in severe hemodynamic compromise in massive PE], hypoxaemia with 5L of supplemental oxygen], diffuse crackles throughout the both lungs.
Was confused with D[ cardiac temponade].
Rule out point: clear lungs in temponade.
very interesting Q.
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| arlete
Intern in 2009!!!!!
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Agree with shahnaz.r. 
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| mildus
Forum Guru
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It looks like pulmonary embolism (acute shortness of breath, increased HR, tachypnea, hypoxaemia with hypocapnia and resp.alkalosis, increased JVP and decreased BP) but in PE lungs are usually clear.
In tamponade also there is increased JVP, low BP, there is tachycardia and tachypnea, I think heart sounds would be silent (this patient has S1 and S2 normal).
Diffuse crackles would rather go with pulmonary oedema as a result of left ventricular failure. Signs of right ventricular failure are absent (except increased JVP). Strong apical impulse is a sign of ventricular hypertrophy, I wouldn't think it would be present in tamponade and PE. S3 can be a sign of heart failure.
So, I am not so sure
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