Quote:
Originally Posted by IMG SURVIVOR
A 64-year-old woman is evaluated for acute dyspnea 3 days after discharge following an inferior myocardial infarction. When she was hospitalized, urgent coronary angiography showed single-vessel coronary artery disease with occlusion of her mid-right coronary artery. She underwent successful stenting of her right coronary artery, and was discharged on her third hospital day. Her ejection fraction was 50% with inferior wall hypokinesis before discharge.
The patients dyspnea began 30 minutes ago. On physical examination, her pulse rate is 110/min, respiration rate is 34/min, and blood pressure is 100/60 mm Hg. Jugular venous pressure is elevated at 10 cm H2O, crackles are heard halfway up both lung fields, a parasternal lift is appreciated, and there is a new grade 3/6 systolic murmur at the left sternal border with an S3 gallop. The electrocardiogram shows sinus tachycardia with Q waves and T wave inversions in leads II, III, and aVF, and is unchanged from the discharge electrocardiogram.
A pulmonary artery catheter is placed, which shows the following:
Pressure (mm Hg) Oxygen Saturation (%)
Right atrium 12 (normal 2-7) 49 (normal 60-75)
Right ventricle 60/12 (normal 20-30/2-7) 78 (normal 60-75)
Pulmonary artery 60/32 (normal 20-30/10-15) 80 (normal 60-75)
Pulmonary capillary wedge 24 (normal <14) 98 (normal >93)
Which of the following is the most likely diagnosis?
A. Papillary muscle rupture
B. Ventricular septal defect
C. Pericardial tamponade
D. Recurrent myocardial infarction
E. Atrial septal defect
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the answer is B.
here's why:
first : of all the timing of the incident is 3 day post mi. this is the perfect time for interventricular rupture. also the chance for an interventricular rupture is increased due to an inferior mi
second: the physical shows signs of volume overload in the right sided circulation and also a holosystolic murmur and a parasternal lift.
third: the EKG rules out a reccurent MI ( although i would compliment it with a second CK_MB level... but that's just me!!!).
fourth and most impo: the readings of the Right sided cath:
A STEP UP IN BOTH O2 AND PRESSURE READING S IN THE RT VENTRICLE AND THE PULMONARY ART.====>LT TO RT SHUNT.
so the answer is :B ventricular septal defect