Case 48

HPI

87 y/o F w/ pmh of COPD, HTN, PUD, presents with several weeks of increasing SOB , chills, weakness, malaise. Patient had a UTI approximately 3 weeks ago and suffered a fall which resulted in a right lower extremity wound. The wound became infected and pt was started on cipro. Over past two weeks pt has become SOB, yesterday it worsened acutely. Today her daughter became concerned and brought her to ED.

ROS

Constitutional: See HPI.
Eyes: No visual changes, eye pain or discharge.
ENMT: No hearing changes, pain, discharge or infections.
Cardiac: No chest pain. +SOB
Respiratory: + cough, respiratory distress.
GI: No nausea, vomiting, diarrhea or abdominal pain.
GU: No dysuria, frequency or burning.
MS: No myalgia, muscle weakness, joint pain or back pain.
Neuro: No headache or weakness. No LOC.
Skin: No skin rash.
Endocrine: No history of thyroid disease or diabetes.

EXAM

Vitals: T: 96.5 oral; HR: 160; BP: 125/64; RR: 24;  O2: 98% bipap
CONSTITUTIONAL: Female patient sitting on stretcher, sob, but speaking full sentences.
NECK: Supple non-tender; no cervical lymphadenopathy.
ENT: Moist mucous membranes.
CARDIOVASCULAR: Tachycardiac. No murmurs. Radial pulses 2/4 b/l. DP and PT pulses 2/4 b/l. No JVD.
RESPIRATORY: Breath sounds present b/l diminished with to L lung field with poor air exchange. Poor resp effort and excursion. Crackles present to lower lung fields L>R (+) Supraclavicular accessory muscle use. (+) Tachypnea. No stridor.
GI/GU: BS present throughout all 4 quadrants; soft, non-distended; non-tender; no rebound tenderness and guarding.
BACK: No evidence of trauma or deformity. No CVA tenderness.
EXT: Full active ROM in all four extremities; R tib-fib with overlying healing ulcer. RLE swollen compared to LLE. No calf pain/swelling/erythema.
SKIN: No rash. RLE with healing ulcer surrounding by erythema and warmth to palpation. Mild streaking. No crepitus.
NEURO: AAOx3.

VIDEO 1

VIDEO 2

QUESTIONS

  1. What do you see in video 1?
  2. An intervention was performed, based on video 2, what was the medication given and what do you see?
  3. What view is used in video 1 and video 2?
  4. What probe was used to obtain these images?
  5. Name the chambers in video 2.

ANSWERS

  1. This is an A4 view in which you see a tachycardic heart. The chambers are all appropriate sizes, with no signs of pericardial effusion or right heart strain.
  2. This patient was given adenosine for SVT. In the video, you can see slowing of the heart.
  3. Video 1: A4; Video 2: Parasternal Long axis view
  4. phased array probe
  5. See image below
Image taken from: http://sinaiem.us/med-students

Image taken from: http://sinaiem.us/med-students