Patient is a 48yr old female , who presented to us with c/o SOB GRIII /IV NYHA
cough
Low grade fever
swelling all over body
since 8 days
She was treated at various hospitals for her condition diagnosed from LRTI to pericardial effusion.
Clinically she had tachycardia, BP was 100/70
Pitting pedal edema
Full JVP
CVS
APEX L 5TH ICS INSIDE MCL
PROMINENT EPIGASTRIC N SUPRASTERNAL PULSATIONS
PALPABLE P2
Loud P2
PSM GR III at TA
RS
trachea central
B/L crepts IMA ISA L>R
ECG findings :
P pulmonale in lead II(RAE)
right Axis deviation
R positivity in V1 V2
(RVH)
incomplete RBBB
I performed a bedside ECHOCARDIOGRAPHY
WITH FOLLOWING FINDINGS
DILATED RA RV
RVID 38mm
Severe TR
TR Vmax 3.6 m/s
Tr Max PG 56 mm Hg
Mild PR
CLOT in RA Appendage
And CLOT IN RV APEX (15-20cc each)
DILATED IVC (18.5mm)
Since ECHO was bedside it remains to be checked if there was an ASD or not.(on a better machine maybe)
patient was started on Anticoagulants immediately with target INR 2.5-3.5.
Pulmonary embolism is often missed out on routine diagnosis.
The triad of Cough ,Shortness of breath , Hypotension must be kept in mind for every patient with unexplained symptoms.
This patient had cardio megaly on x ray
And poor R progression inECG
She was misdiagnosed as CAD n LRTI
In this case patient presented when she developed CCF secondary to Right sided failure.
So moral of the story : Always think of PULMONARY EMBOLISM whenever any pt presents with unexplained cough DYSPNEA .
Corelation of CLINICAL FINDINGS, ECG AND ECHO ARE A MUST.
Images attached.
Comments n queries most welcome..
Update : 22/01/2014
Cardiologist opinion is that its a RV Cyst n not a clot.
Were searching for cysts in other areas
