{"id":1581,"date":"2020-05-21T00:43:38","date_gmt":"2020-05-21T00:43:38","guid":{"rendered":"http:\/\/emultrasound.sdsc.edu\/?p=1581"},"modified":"2020-08-17T20:12:09","modified_gmt":"2020-08-17T20:12:09","slug":"28-year-old-with-sob","status":"publish","type":"post","link":"https:\/\/emultrasound.ucsd.edu\/index.php\/2020\/05\/21\/28-year-old-with-sob\/","title":{"rendered":"Case # 21: A 28 Year Old With Shortness of Breath"},"content":{"rendered":"
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A previously healthy 28-year-old male presents to the Emergency Department complaining of one month of fatigue, shortness of breath, and dyspnea on exertion. These symptoms were preceded by symptoms of a viral illness which initially improved; however, he had recurrence of symptoms two weeks ago. He was seen at urgent care five days ago and was given steroids and albuterol without improvement. The patient otherwise denies any infectious symptoms, leg swelling, or risk factors for pulmonary embolus or deep vein thrombosis.  <\/p>\n

VS: T: 97.7F    BP: 129\/87.    HR: 109     RR: 16.    SP02: 95%<\/p>\n

Patient is alert and oriented, non-toxic in no distress, and behaving appropriately. Cardiac exam shows a RRR, no murmurs, rubs, or gallops. Lung exam is consistent with shallow breaths and dyspnea with conversation, otherwise lungs are CTAB with no wheezing, rales, or rhonchi. The patient has no chest wall tenderness, no JVD, and no lower extremity edema.<\/p>\n

You perform a bedside ECHO and you see the following. What do you see and what is your most likely diagnosis? What is your next step in management?<\/p>\n<\/div>\n<\/div>\n<\/div>\n

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\"apical<\/div>\n<\/div>\n
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\"psla<\/div>\n<\/div>\n<\/div>\n
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\"pssa<\/div>\n<\/div>\n
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Answer and Learning Points<\/h3>
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Answer: <\/span><\/strong><\/p>\n

In all three cardiac views, there is dilation of the right side of the heart. In the parasternal short axis you see septal bowing into the left side of the heart, also known as the \u201cD\u201d sign (named after the shape of the left ventricle). These findings are indicative of elevated right sided pressure, or right heart strain, which can be seen in conditions such as acute pulmonary embolism, pulmonary hypertension, COPD, and right ventricular infarction. Given the relatively thin free wall of the right ventricle, the likely cause of right heart strain in the above scenario is an acute process. <\/span><\/p>\n

The patient had a CT scan that revealed extensive pulmonary emboli in all segmental and subsegmental arterial divisions of the lung with findings consistent with pulmonary artery hypertension and severe right heart strain. The EKG obtained had evidence of right heart strain including right axis deviation and diffuse T-wave inversions. The patient was started on heparin and admitted to the ICU.<\/span><\/p>\n

Learning Points<\/span><\/strong><\/p>\n