An interesting case of ?RV CYST ?Pulmonary Embolism

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

ECHO-an interesting case of VHD with LA CLOT

30/F presented with SOB GR IV NYHA
PALPITATIONS

CVS : apex L 5ics inside MCL tapping character DIASTOLIC THRILL at MA
MA : LOUD S1
GR IV MDM at MA low pitched best heard with BELL with
TA : gr III murmur HIGH pitched best heard with diaphragm at end inspiration.
AA : MUFFLED S2 ESM GR4 WITH THRILL best heard at end expiration in sitting position slightly leaning forwards radiating to carotids
EDM at NAA GR III
ECHO :
CALCIFICATIONS IN MV AND AV
SEV CRITICAL MS (MVA 0.59 cm2 BY PHT
0.8 cm2 by MV planimetry
SEV AS WIT AR
AvVmax >4m/s
SEV TR WITH SEV PAH the TR JET is biphasic with one central and one eccentric towards IAS
PASP >100MMHG
Large LA Clot

A case of DCMP with LV APICAL ANEURYSM with Aneurysmal clot

60/M presented to the ECHO ROOM referred from Opd with c/o SOB CHEST PAIN, palpitations.
When I got the PLAX view I could see an aneurysm. Interestingly this aneurysm also had a clot which was attached at one end and other end was floating. There was also spontaneous ECHO contrast which indicated blood stasis.A4C gives a better view of the aneurysm and the clot. He also had severe MR & TR.LVEF by Simpsons was just 12%