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  #1  
Old 03-13-2012
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Question 50-yr-old woman with dyspnea and chest pain; next step

A 50-year-old woman has had progressive dyspnea over the past 2 weeks and constant, sharp chest pain for 4 days. The pain is localized to the center of the chest and is worse while supine. She underwent a right, modified radical mastectomy and adjuvant chemotherapy for breast cancer 3 years ago. She has a history of hypothyroidism treated with thyroid replacement therapy. She has smoked one pack of cigarettes daily for 30 years and drinks two ounces of alcohol daily. She is dyspneic and diaphoretic. Her temperature is 37.2 C (99 F), blood pressure is 90/70 mm Hg with a pulsus paradoxus of 20 mm Hg, pulse is 110/min, and respirations are 28/min. Examination shows jugular venous distention to the angle of the mandible. The liver span is 14 cm with 4 cm of shifting abdominal dullness. Arterial blood gas analysis on room air shows a pH of 7.50, PCO2 of 30 mm Hg, and PO2 of 70 mm Hg. An x-ray film of the chest shows an enlarged cardiac silhouette with a globular configuration. An ECG shows sinus tachycardia with nonspecific ST-segment changes diffusely. Which of the following is the most appropriate next step in management?

A) Echocardiography
B) CT scan of the abdomen
C) Ventilation-perfusion lung scans
D) Bronchoscopy
E) Paracentesis

Last edited by achistikbenny; 03-13-2012 at 02:46 AM.
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  #2  
Old 03-13-2012
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a?
Cardiac tamponade?? needs echo for dx.:sorry:
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  #3  
Old 03-13-2012
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I think it's E because cardiac temponade is an emergency situation!!!
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Old 03-13-2012
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Yes i also think this patient has massive pulmonary embolism and has symptoms and signs of rt heart failure bcos of acute heart strain. this patient probably has metastatic cancer disease and therefore hypercoagualable state seen in malignancy. And this in addition to her cigar smoking can increase and precipitate thrombus formation that can led to migrating emboli to the pulmonary system. Her ABG is aslo in support of pulmonary embolism.thats my own logical reason. so ANS C.
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Old 03-13-2012
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i think c.
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  #6  
Old 03-13-2012
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you mean enlarged cardiac silhoutte on xray...

is due to massive pul embol ??

i think ans is

PARACENTESIS ...??? i thot it was supposed to be a PERI-CARDIO-CENTESIS

so the ans should be and " emergency echo !! "

thou i m not sure

and BTW the dyspnoea might be due to pulm congestions...!!
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  #7  
Old 03-13-2012
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Her problem is no longer an acute thing so right heart failure due to massive pulmonary emboli will eventually led to left heart failure due to decrease cardiac output and left ventricular failure
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Old 03-13-2012
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how did the massive PE lead to THE HEPATOMEGALY... and shifting dullness

so acutely ??

cmon i think there r enof clues... for post radiation pericarditis with tamponade...

plus a massive pul embol wud be REALLY ACUTE... not with 2 weeks of dyspnea

Plus the classic chest pain suggestive of pericarditis...

hw do u guys overlook these obvious clues !!

look at po2...70 mm... cmon man... where is the HYPOXIA in PE ?????

now do u guys get it ?

now the question is ECHO or paracentesis ...?
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Old 03-13-2012
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Definitely A.
Paricardiocentesis is usually Echo guided procedure nowadays. You don't just poke a needle in pericardium blindly.
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  #10  
Old 03-13-2012
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massive pulmonary emboli can give signs of right heart failure including hepatomegaly. thats is in u world. also pulmonary emboli give respiratory alkalosis bcos the problem is not a ventilation problem but a perfusion problem.
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  #11  
Old 03-13-2012
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this woman did not undergo radiation therapy .she had a radical mastectomy with adjuvant chemotherapy
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Old 03-13-2012
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Quote:
Originally Posted by achistikbenny View Post
Her problem is no longer an acute thing so right heart failure due to massive pulmonary emboli will eventually led to left heart failure due to decrease cardiac output and left ventricular failure
what??????????????????????????
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  #13  
Old 03-13-2012
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Quote:
Originally Posted by achistikbenny View Post
massive pulmonary emboli can give signs of right heart failure including hepatomegaly. thats is in u world. also pulmonary emboli give respiratory alkalosis bcos the problem is not a ventilation problem but a perfusion problem.
A 50-year-old woman has had progressive dyspnea over the past 2 weeks and constant, sharp chest pain for 4 days. The pain is localized to the center of the chest and is worse while supine. She underwent a right, modified radical mastectomy and adjuvant chemotherapy for breast cancer 3 years ago. She has a history of hypothyroidism treated with thyroid replacement therapy. She has smoked one pack of cigarettes daily for 30 years and drinks two ounces of alcohol daily. She is dyspneic and diaphoretic. Her temperature is 37.2 C (99 F), blood pressure is 90/70 mm Hg with a pulsus paradoxus of 20 mm Hg, pulse is 110/min, and respirations are 28/min. Examination shows jugular venous distention to the angle of the mandible. The liver span is 14 cm with 4 cm of shifting abdominal dullness. Arterial blood gas analysis on room air shows a pH of 7.50, PCO2 of 30 mm Hg, and PO2 of 70 mm Hg. An x-ray film of the chest shows an enlarged cardiac silhouette with a globular configuration. An ECG shows sinus tachycardia with nonspecific ST-segment changes diffusely. Which of the following is the most appropriate next step in management?

A) Echocardiography
B) CT scan of the abdomen
C) Ventilation-perfusion lung scans
D) Bronchoscopy
E) Paracentesis
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  #14  
Old 03-13-2012
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@ benny please share the actual ans...
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  #15  
Old 03-13-2012
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the ans is A. its just that am not satisfied with the ans . that is why i needed more explanation.
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  #16  
Old 03-14-2012
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E - - -based on step 1 knowledge,,seemed like cardiac tamponade so paracentesis required . .
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  #17  
Old 03-15-2012
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well even i thought its E but reading i goota knw tht pt dint present to the emergency or in acute situation and is hving symptoms since 4 days ! ! so may be ECHO wud be quite acceptable to confirm the DX of tamponade and then perform the pericardiocentesis !
wat say folks ??

so ans may be A
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  #18  
Old 03-27-2012
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It s tamponade ..i m with a...
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  #19  
Old 03-27-2012
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Quote:
Originally Posted by achistikbenny View Post
A 50-year-old woman has had progressive dyspnea over the past 2 weeks and constant, sharp chest pain for 4 days. The pain is localized to the center of the chest and is worse while supine. She underwent a right, modified radical mastectomy and adjuvant chemotherapy for breast cancer 3 years ago. She has a history of hypothyroidism treated with thyroid replacement therapy. She has smoked one pack of cigarettes daily for 30 years and drinks two ounces of alcohol daily. She is dyspneic and diaphoretic. Her temperature is 37.2 C (99 F), blood pressure is 90/70 mm Hg with a pulsus paradoxus of 20 mm Hg, pulse is 110/min, and respirations are 28/min. Examination shows jugular venous distention to the angle of the mandible. The liver span is 14 cm with 4 cm of shifting abdominal dullness. Arterial blood gas analysis on room air shows a pH of 7.50, PCO2 of 30 mm Hg, and PO2 of 70 mm Hg. An x-ray film of the chest shows an enlarged cardiac silhouette with a globular configuration. An ECG shows sinus tachycardia with nonspecific ST-segment changes diffusely. Which of the following is the most appropriate next step in management?

A) Echocardiography
B) CT scan of the abdomen
C) Ventilation-perfusion lung scans
D) Bronchoscopy
E) Paracentesis









ans is A.sinario is typical for cardiac tamponad.PE IS sudden onset it not take even aday.
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  #20  
Old 08-18-2015
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Default WELS criteria in referance to answer the question

I just gave nbme form 6 and I answered paracentesis for this. Turns out it was wrong. With that in mind we have to decide between V-P scan and Echo. On one hand echo should be done as dyspnea has been there for 2 weeks. That coupled with a globuled with a globular heart only makes you suspect more.

If it was PE we would have a more acute setting of dyspnea. Although fever and tachycardia and history of smoking along with pleuritic chest pain is indicative of that. ABG values also favor a PE. But if we consider the WELS criteria for PE the score turns out to be unlikely. WELS criteria is as follows:

Clinical symptoms and signs of DVT = 3
alternative diagnosis less likely than PE = 3
Heart Rate >100 = 1.5
Immobilization for more than 3 days = 1.5
Previous PE or DVT = 1.5
Hemoptysis = 1
cancer ( with treatment within past 6 months or palliative care) = 1

PE likely = score > 4
PE unlikely = score <4
(Reference CMDT 2014)

With the WELS score the big that I am concerned about is "ALTERNATIVE DIAGNOSIS LESS LIKELY THAN PE" because that will contribute 3 points and shift the diagnosis in favor of PE.

I guess the only way to know for sure is for someone to give NBME one more time and select C or A as an answer.
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  #21  
Old 09-01-2015
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Default constrictive pericarditis

well, i think there should be no confusion..this is a case of constrictive pericarditis with all signs and symptoms with it..and it should be confirmed first with ECHO..a very simple question i guess
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  #22  
Old 09-02-2015
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A. Paracentesis term is used for peritoneal cavity.
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