Test Yourself

Case 1

HISTORY

This patient had metastatic cervical cancer. She presented with her fourth episode of severe sharp, non pleuritic chest pain.  

She was slightly sweaty but talking comfortably at rest.

Temp 37.7   Pulse 120  sinus rhythm   BP 105 / 60   Sats 96%    Resp Rate 20

I was asked to FOCUS (FOcused Cardiac UltraSound)

?Tamponade, ?Pulmonary embolism, ?Pleural Effusion, ?Ischaemia, ?other

ULTRASOUND FINDINGS

Subcostal View:

No tamponade. RV a little bigger than usual, RV free wall thickness normal. IVC measurement suggests central pressures around 15 mmHg.

Parasternal Long Axis:

Left atrium looks normal, as does the mitral valve. LV unremarkable, and the aortic valve and proximal aorta and fairly unremarkable.

Parasternal Short Axis:

Here the RV is clearly larger than the usual 2/3 or less of the LV. In addition there is flattening of the interventricular septum (D-shaped) indicating elevated right ventricular pressure.

Apical 4 Chamber:

Here again the RV is larger than usual, and is not contracting normally, with the tricuspid annulus not moving towards the apex as much as usual. The tip of the right ventricular apex appears to be hyperdynamic

The interatrial septum is deviated to the left, indicating elevation of the right atrial pressures relative to the left.

The peak gradient across the tricuspid valve is elevated indicating raised PA pressures.

All these findings are consistent with pulmonary embolism, and in the clinical context this is the most likely diagnosis. Unfortunately good transthoracic echo views of the pulmonary artery could not be attained.

This was confirmed with CTPA.


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Subcostal View

No pericardial fluid. RV perhaps a little big.
Subcostal View RV Free wall thickness IVC IVC Subcostal Short Axis View Parasternal Long Axis (PSLX) PSSX Aortic Valve Parasternal Short Axis Midpapillary View Apical 4 Chamber View Peak Tricuspid Gradient CT Pulmonary Angiogram CT Pulmonary Angiogram