Respiratory - Capsule Cases

Question 1

You are asked to see a 62-year-old female on the ward who has developed severe shortness of breath. This has been of sudden onset and is associated with mild central chest discomfort but no significant cough or sputum production. The patient has recently been moblised following admission and treatment for a chest infection. The patient is not taking other medication and has no other significant medical history of note.

On examination, she is unwell, appears pale, clammy and poorly perfused peripherally. She has a temperature of 37.2°C, pulse 110bpm regular and blood pressure 80/50 mmHg. There is elevation of the jugular venous pressure but heart sounds appear normal and chest examination is unremarkable. Her abdomen is soft and non-tender there is no evidence of lower limb oedema and no significant abnormality is apparent on initial neurological examination. Results of initial blood investigations including full blood count and urea and electrolytes are available with no significant abnormalities.

What is the most likely diagnosis

Answer 1

Pulmonary Embolism

The most likely diagnosis is that of a massive pulmonary embolism. The combination of sudden severe shortness of breath, shock and elevation of jugular venous pressure secondary to right heart strain are consistent with this diagnosis. Pulmonary embolism may be associated with central chest discomfort only when massive and indeed chest pain may not be a feature. Smaller emboli may present with more pleuritic type chest pain and haemoptysis. The normal chest examination would make pneumothorax and pneumonia less likely and the history is not typical for myocardial infarction (severe central chest pain, crushing in nature with radiation often to left arm or jaw) or aortic dissection (central chest pain which may radiate to the back and is often described as “tearing” in nature).

Question 2

What is shown by this chest xray

Answer 2

It is normal

Question 3

You are asked to see a 62-year-old female on the ward who has developed severe shortness of breath. This has been of sudden onset and is associated with mild central chest discomfort but no significant cough or sputum production. The patient has recently been moblised following admission and treatment for a chest infection. The patient is not taking other medication and has no other significant medical history of note.

On examination, she is unwell, appears pale, clammy and poorly perfused peripherally. She has a temperature of 37.2°C, pulse 110bpm regular and blood pressure 80/50 mmHg. There is elevation of the jugular venous pressure but heart sounds appear normal and chest examination is unremarkable. Her abdomen is soft and non-tender there is no evidence of lower limb oedema and no significant abnormality is apparent on initial neurological examination. Results of initial blood investigations including full blood count and urea and electrolytes are available with no significant abnormalities.

What is shown by the patients ECG?

Answer 3

First Degree AV block and right bundle branch block

See the ECG strip in the image below. The ECG demonstrates 2 main waveform abnormalities:

first degree AV block: note markers in lead 2 showing the lengthened PR interval

right bundle branch block: note the wide secondary R-wave in the right chest leads arrowed in V1, and the deep S-wave arrowed in V6

Question 4

With regard to ECG changes in acute massive pulmonary embolus which of the following statements are true?

• S1 Q3 T3 pattern is the commonest ECG abnormality
• ECG abnormalities are common and are seen in most patients
• The ECG may be normal
• Right bundle branch block may occur
• Left sided ECG abnormalities exclude the diagnosis of pulmonary embolus

Answer 4

• ECG abnormalities are common and are seen in most patients
• The ECG may be normal
• Right bundle branch block may occur

The ECG is normal in up to 15% of cases. The so called “S1 Q3 T3” pattern associated with acute massive pulmonary embolus is relatively rare. Other non-specific ECG abnormalities are more common including sinus tachycardia, atrial fibrillation, first degree AV block and right bundle branch block. Left sided ECG abnormalities are unusual but may occur in acute massive pulmonary embolus.

Question 5

The image below was taken from a CTPA study at the level of the main pulmonary arteries. Order the parts of anatomy in descending order (first to last) as labelled A-F

Answer 5

A = Ascending Aorta

B = Decending Aorta

C = Superior Vena Cava

D = Main Pulmoary Trunk

E = Thrombus in the right pulmonary artery

F = Thrombus in the left pulmonary artery