Mon25October0844PM 3

A 37-year-old lady is brought to the Emergency department with rapidly increasing breathlessness and chest pain over the preceding 48 hours.

She had been under the care of rheumatologists for joint symptoms and has been diagnosed with systemic lupus erythematosus (SLE). There is no history of recent travel or symptoms to suggest infection.

On examination the patient is short of breath with a respiratory rate of 26. Oxygen saturations are 97% on room air. Pulse is 130 regular and blood pressure is 80/60 mmHg. Cardiac examination is unremarkable but the venous pressure is elevated. There is no peripheral oedema.

A 12 lead ECG reveals a sinus tachycardia only. A chest x ray demonstrates a slightly enlarged heart but clear lung fields.

Which is the most appropriate next step in this patient's management, from the list below?

(Please select 1 option)

Urgent transthoracic echocardiogram This is the correct answer

Urgent CT pulmonary angiogram

Full dose low molecular weight heparin

Intravenous furosemide

Start ionotropic agents Incorrect answer selected

Explanation

This question is difficult.

The case describes a patient with lupus and acute breathlessness. The symptoms and haemodynamic parameters are a worry - urgent diagnosis and management are essential.

The features of the history could be due to pericardial effusion or pulmonary embolism (PE) (both increased risk with SLE). The normal oxygen saturations and slightly enlarged heart point away from PE, and make pericardial effusion more likely. We are not told if pulsus paradoxus is present.

Cardiac examination can be normal with a pericardial effusion. An urgent echo will exclude a significant pericardial effusion. It will also provide information on evidence of tamponade physiology.

It is rare to diagnose PE with an echo, but it is useful in detecting right heart dilatation/impairment and pulmonary hypertension which can be strongly suggestive of a diagnosis of PE.

Therefore, from this list, an urgent echo is the most appropriate. A computed tomography pulmonary angiogram (CTPA) would rule out PE and could demonstrate an effusion, but would not reveal tamponade changes.

Answer Statistics

1

53%

2

28%

3

17%

4

4%

Times answered: 282