Cardio#5

[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

[blackwolverine]

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

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

[IMG SURVIVOR]

I will tell you soon if you are right or wrong